Possible VA Change in Advanced Nursing Roles Sparks Heated Debate

By Sandra Basu

WASHINGTON — Amid heated controversy, the VA is considering a proposal that would require VA’s Advanced Practice Registered Nurses to be designated as independent practitioners, regardless of individual state regulations.

The proposal, included in a draft copy of VA’s nursing handbook, is designed to  “reduce variability in practice across the entire VA health care system,” among other issues, according to VA.

A letter sent to the VHA this past fall by 43 state medical organizations and 23 national organizations, however, strongly denounces the proposed change and urges that “revisions be made to the draft VHA Nursing Handbook to ensure that current VHA policies in support of physician-led health care teams and state-based licensure and regulation remain unchanged.”

“APRNs are indispensable, but they cannot take the place of a fully-trained physician,” the letter states.


pencil_white.jpgOpinion poll:
Should the VA standardize practice across all facilities for nurses with advanced training?

Please click here to participate in this month’s U.S. Medicine readership poll.


While all APRNs have at least a master’s degree in nursing, their scopes of practice vary from state to state with some jurisdictions requiring physician oversight in patient care and others granting more autonomy, including allowing independent evaluation and diagnosis of patients as well as prescription authority.

Scope of practice for top-level nurses in the United States has been the subject of continuing debate. Fueling that conversation was a 2010 Institute of Medicine (IoM) report sponsored by the Robert Wood Johnson Foundation Initiative on the Future of Nursing that recommended the removal of scope of practice barriers for APRNs so that they are able to practice to the full extent of their education and training.

Ann Thrailkill, FNP, a nurse practitioner at the VA Palo Alto Healthcare System (right) consults with a patient at the Women Veterans Health Center last year. Photo by Joseph Matthews/Palo Alto VA

Ann Thrailkill, FNP, a nurse practitioner at the VA Palo Alto Healthcare System (right) consults with a patient at the Women Veterans Health Center last year. Photo by Joseph Matthews/Palo Alto VA

“As the healthcare system has expanded over the past 40 years, the education and roles of APRNs, in particular, have evolved in such a way that nurses now enter the workplace qualified to provide more services than had been the case previously,” the IoM committee stated.

The IoM pointed out, however, that because “licensing and practice rules vary across states,” the regulations regarding scope of practice “have varying effects on different types of nurses in different parts of the country.”

“For example, while some states have regulations that allow nurse practitioners to see patients and prescribe medications without a physician’s supervision, a majority of states do not. Consequently, the tasks nurse practitioners are allowed to perform are determined not by their education and training but by the unique state laws under which they work,” a brief summary of the report noted.

Pointing to these varying state laws was a June 2013 Robert Wood Foundation brief on APRNs in the Charting Nursing’s Future series. It stated that, because of varying rules concerning prescriptive authority, admissions and physician supervision, VA APRNS often have to change the way they practice based on location, even when treating the same patient.

Physicians Object

Several groups, however, say greater independence of APRNs is not the correct approach. American Academy of Family Physicians President Reid Blacwelder, MD, told U.S. Medicine that, while every member of the healthcare team has a unique and indispensable role, those roles are not interchangeable. Even states that have independent practice for APRNs still struggle with access and patient-outcome issues, Blackwelder pointed out.

“So, instead of segmenting our healthcare system further and creating silo groups of independent practitioners doing their thing, we really need to be shifting across this country to team-based care,” he said.

Blackwelder said that VA has been a leader in the team-based concept but warned that the VA’s consideration of new roles for advanced-practice nurses is “a major change with unforeseen consequences.”

In a letter to VHA, the AAFP and other organizations said that the draft VHA Nursing Handbook “effectively eliminates physician-led, team-based care within the VHA.”

“Health care leaders like Geisinger Health System, Intermountain Healthcare, the Mayo Clinic and Kaiser Permanente are successfully using physician-led teams to achieve improved care, improved patient health and reduced costs,” the letter states.

The threat to team-based care is also among the concerns of the American Society of Anesthesiologists. It warned that the changes to the role of Certified Registered Nurse Anesthetists (CRNA) would “dramatically change surgical anesthesia care” in the VHA. It has urged its membership to contact their lawmakers and ask them to support ASA’s efforts to preserve current anesthesia policies within the VA.

Supporters of VA’s proposed changes for APRNs say that those concerns are unfounded.

“Team-based care is important. I don’t see this as diminishing team-based care. All licensed professionals should work to the top of their education level and experience,” said Andrea Brassard, PhD, FNP-C, FAANP, the American Nurses Association’s (ANA) Senior Policy Fellow for Nursing Practice & Policy.

In the VA, Brassard told U.S. Medicine, the change would “make the care to the veterans more consistent from state to state.”

The ANA was one of 40 nursing organizations that signed a letter to VA Secretary Eric Shinseki in October, stating that the proposed change “will further facilitate timely delivery of high-quality health care” to veterans.

Shinseki also defended the proposed policy’s impact on CRNAs in a letter to lawmakers, stating that the “available evidence does not substantiate that independent CRNA practice presents a threat to health and safety or in any way lowers the quality of anesthesia care.”

“The proposed policy for VHA, an integrated federal healthcare system, follows similar policies for CRNA practice in the Department of Defense and the Indian Health Service, with the intent to enhance the quality and access to care for all veterans across the entire VA health care system,” he wrote.

Meanwhile, VA Undersecretary for Health Robert Jesse, MD, PhD, told lawmakers at a hearing this past fall that VA “will not move anything forward until we’ve had robust discussions with external stakeholders including the societies.”

“I know ASA is very interested in this, I know the family practice folks are very interested, and AMA is very interested,” he said at the time.

A VA spokesperson said the public will have an opportunity to comment when the draft Nursing handbook is put into the Federal Registry for a 90-day period Following the public comment period the VHA Under Secretary for Health “will render a decision on the policy,” according to the spokesperson.

Comments (105)

Trackback URL | Comments RSS Feed


    As a Board Certified Hospice and Palliative Care Nurse Practitioner (ACHPN) I am dissappointed in the archaic laws in the Florida Nurse Practice Act which limit Nurse Practitioners from prescribing medications to treat patients’ pain and symptoms. Waiting for a physician to cosign my orders before the pharmacy will process the medications causes unacceptable delays for my patients who are suffering.

    • Mary Kastner says:

      I would agree. I had to wait 2 yrs at VAPAHCS to utilize my DEA license and it still wasn’t happening so I had to leave and went 30 miles away to NCHCS where I prescribe schedule II through V. I did this to provide better customer service. When patient’s have to wait or make return visits just because an MD who didn’t see the patient hasn’t signed the order I put in in the MD’s name is not right.

      • Lee Smith says:

        Ms. Kastner, you have a DEA license as federal law requires such for the dispensing of any prescription strength medication. As you well know, your limitation(s) of medical practice is for, first and foremost, state law that CANNOT be summarily dismissed by the feds – Read: Sovereignty rights. I find it rather disturbing that you would refer to a patient, and their treatment, as “customer service”?

        As a final note, I do trust Nurse Practitioners immensely, the adage of ‘trust but verify’ definitely applies. Why? I am allergic to Cipro and Keflax and that is noted in my records, yet a ARNP either overlooked or ignored that fact and prescribed me Cipro. I suffered a psychotic event for four days that resulted in my being restrained in a bed. Mistake? Inexcusable.

        I hold a Bachelors, Masters and PhD in Computer Science and Information Security and have 30 years experience. But I can’t teach at any level of education. Why? State and Federal Laws as I do not have teaching credentials. You do not have an MD/DO, nor the extensive education and training.

    • Joanne says:

      As a long time RN, yes. NP’s function within their role – for the most part – well. But, you are NOT MDs. MDs are scientists spending years training and studying this practical application of science. As far as MS programs go — you’re almost guaranteed obtaining it once one starts the program. It ain’t so in Med School.

    • John says:

      Healthcare is best given as a team. I received twice the biology, chemistry and physics to get a degree in public health as the NP’s do in my state (I used to help teach their chemistry class). NP’s have a great role in healthcare, but they should not be allowed to practice independently of a team with a physician. Human physiology is way to complex. You can’t understand systemic vascular resistance or respiratory physiology or pathophysiology without a minimum of a year of college level physics. NP’s have less than half the years of education of most physicians and when you compare the course load in the graduate level programs they even then vary. Most NP programs take a standard semester hour load in grad school while medical school students take over 20 s.h. a semester. I wouldn’t feel safe being treated by an independent NP with half the years of education, no science background and taken smaller course loads while in school.

      • Dennis says:

        I work as a CRNA, and have 2 years of biology, 4 pathophysiology courses, chemistry to include general and organic, and biochemistry. I have studied the USMLE 1 & 2, and feel confident I could pass these exams. I worked in critical care setting for 5 years where there was no residents or interns. We titrated the inotropes, and timed the IABP’s, interpreted the PABTC information, etc,. I have delivered anesthesia for 15 years now, and my opinion is this, anesthesia is a numbers game, like many occupations, the more you are exposed to, (central line placement, regional blocks, etc) the better one is going to get at doing these procedures, and the more one will grow. Should all CRNA’s be pacing blocks or doing complex cases? Hell no, as in anything one needs to be open to who the strong players are and who should be in the cataract rooms. The same can be said for medical doctors, just because one has MD/DO after their name doesn’t preclude them from error or elevate their practice to a better level.

      • Rene says:

        It is my understanding that there are physicians in the USA that have come here from other countries and have the equivalent of a Bachelors or Masters Degree. However, because their country labels it as medical education they are permitted to take the US Medical Board Exam. As a nurse practitioner with 2 yrs of inorganic chemistry, 1 yr of organic chemistry, 2 years of physics, advanced anatomy, advanced physiology, a total of 7 years of graduate education and clinical time, and 3 certifications (women’s health, family, and mental health) I am not viewed as qualified to take the medical board exam. I agree that APRN’s are no different from any other profession. There are great ones and not so great ones. No different from physicians. Look back in history and you will see that it hasn’t been that many years ago that the years of college level education required to become a physician were quite different.

  2. Annette Dawson says:

    Physicians have historically had a difference of opinion when it comes to Nurse Practitioners (APRN). I believe the majority of APRNs who are NP’s are working safely in their specific areas and also have assess to a Physician if needed. I believe VA should invest in the APRN with continuing education which essentially has stopped. Yes we are responsibile for our own knowledge base but so should VA have input into this process to make sure this is indeed happening. I have been a Board Certified NP since 1996 and feel confident I can provide good,safe, proficient quality patient care. I also know my limitations and when it’s appropriate to consult with a Physician. Having said this, I believe many Physicians feel threatened by the NP, for reasons they will not admit. Instead of being negative and feeling we are trying to take their places,we should work collaboratively. Finally, there are bad Physicians and APRNs as well as good, the evidence is clear and available for review on the each state’s respective Department of Health Professionals website for anyone’s review. The research supports NPs as capbale,competent primary providers and we are here to stay.

  3. Nev says:

    Ask the patients themselves. The vast majority of them will prefer that their provider be an MD rather than an APRN.

    The recent investgations of incidents at the VA in Jackson, MS, merely underscore the fact that when providers with less training than MD’s get to practise without supervision (even though that was an unintended, non-legitimate use of such providers), the outsomes are bad and the veterans suffer.

    • Pam says:

      I am a patient, and have always preferred an APRN. Research also significantly reveals increased patient satisfaction and decreased HAIs when an APRN is caring for the patient not to mention decreased length of stay. In part this may NE due to their holistic vision when providing care. 🙂

      • Erin says:

        On what data are you basing that statement? According to data in the IOM report, patient satisfaction ratings are actually higher with APRNs than MDs.

        • Dimetra FNP-C says:

          That is what she is saying. APRNs have shown in various reports to have higher patient satisfaction than physicians.

        • Julie says:

          Only in surveys conducted by physician-run groups like the AMA, which structures their questions like “if you could see a provider with 10 years of training or 5 years of training which would you choose?” The reality is they should say “if you could spend 10 minutes being condescended or 20 minutes of real conversation about your health problems, which would you choose?”

          • Beverly Benmoussa, MSN, APRN, FNP-BC says:

            Yes, the arguments of the physician lobbies are not based on science or evidence.

    • Ellen says:

      I’d be interested in the data that supports the statement that the vast majority of patients prefer their provider be an MD.

    • Erin says:

      Nev, on what data are you basing “the vast majority” of patients prefer an MD? The IOM data actually showed the reverse- patient satisfaction ratings are improved with APRNs. Also, it is important to note that outcomes in states with more regulations (increased physician oversight) are no better than in states that do have this barrier to scope of practice. According to the Institute of Medicine (2011), “states with broader nursing scopes of practice have experienced no deterioration of patient care.” This is nothing more than an outdated, unfounded turf war. Especially with more people having access to care due to the ACA, there is more than enough business to go around. This is particularly true among rural and underserved populations, where a greater proportion of APRNs practice compared to physicians.

    • Chris says:

      It would please me very much to see this “data” that support your proposal that the “vast majority” of patients prefer their provider be an MD rather than an APRN. Because of your lack of citation I can only assume that this is your own personally concocted data rather than something published in a peer reviewed journal. The latter doesn’t exist. Please cease and desist promoting fictions of your own making because your feel some level of turf infringement from APRNs. Thanks.

    • Jackie Sammons, BSN, RN, FNP Student says:

      Respectfully, your comment regarding patient preference for MD v NP is not evidence-based. There is a plethora of research available on the subject. Please cite/share your sources. I was originally going to post links to the research here with my response, but there were too many to post. I found comparisons of patient satisfaction between APNs and MD/DOs in ER, rural, primary care, and specialty practices; most show no significant differences, and where there are differences they lean slightly in favor of NPs because they spend more time with the patients, and their plans of care are more holistic. Please utilize your medical library to do a search if you haven’t done so thus far. If you find conflicting results, please share them with us. We are not threatened to hear constructive feedback.

      Most physicians do not even know what NP education consists of, neither do they know or understand their scopes of practice. I do not know ANY APNs that are in a turf or ego battle, they only want to provide efficient care to their patients, and current laws in some states are barriers to that end. No one argues the education and residency of physicians is more extensive than APN’s, but evidence shows NPs provide safe, effective care…. and physicians have been described (by many) as over-qualified for primary care. Nurses have spent their careers using resources to provide safe care for their patients. We know when to call, collaborate, and refer to physician colleagues.

      If/when patients report a preference for physician providers, it is because they have never seen an NP and/or do not understand what an NP is/does. The American Association of Nurse Practitioners is working to resolve the issue of educating the public, policy makers, and even physicians about just that.

    • geraldine marrocco says:

      You do not have the data to support your statements. Time and time again, surveys and outcome data support the NP as the primary care provider and outcomes are excellent, actually better than MDs. So please be careful with such unsubstantiated public statements.

    • Tracie Girard, RN, MSN says:

      As a student in a FNP program I frequently had patients tell me, unsolicited, of positive experiences they have had with NPs. I never once had person say they prefer a doctor. You see there is room for many types of providers in healthcare. Physicians assume that NPs do not know when to seek assistance or make a referral. Changes in healthcare require collaboration.

    • Jodi Buffington, APRN - BC Psychiatry says:

      That’s bologna.

    • Joanne says:

      Totally agree. I’ve asked to see MD’s in the VA, with the NP getting a bit upset. I think they like the title, but they are not doctors. I don’t mind seeing a practitioner for follow-up after seeing the MD for an initial. I do not trust practitioners for primary care. People unfamiliar with the field just don’t have a frame of reference. They don’t know the difference between an NP and Regular Real Medical Doctor. I see that as misrepresentation re: the scope of practice. Reading these posts there’s a little too much arrogance and arrogance can cause plenty of mistakes.

      It’s the scope of practice that needs to be nailed down.

    • Rene says:

      There are poor providers and great providers in any profession. Speaking from emotion rather than objective data is dangerous and irresponsible. Institutes of Medicine (IOM) has published some scientific articles on patient care, safety, and outcomes. There have been people in all health care professions not meet the standard of care and get into trouble. Rightly so. In my 14 year career I have overall had wonderful experiences in working along side physicians, other nurse practitioners, and other health professionals. When we use our strengths together we provide the highest quality care possible. When people feel threatened, it is a natural reaction to become defensive.

  4. Karl R. Koenig says:

    I fully support the new recommended proposal for full priveleges for advanced practice nurses and CRNA’s throughout the system. I am limited here in Florida at the Bay Pines VA. We are not permitted to prescribe opiates and benzodiazapines here in Florida or the VA. When I went on active duty with the Navy I was permitted to prescribe both. I work on a team with a collaborative psychiatrist but am still restricted under the current status. I fully endorse the independent practitioner concept and believe it would improve accesss and patient care.

    • Lavon Williams, DNP (c), MSN, PMHNP-BC, GNP-BC says:

      I totally agree. It is our time. The physician shortage is not getting better, it’s only getting worse. NPs are the answer to a better health care system overall. This have been proven over and over again. As a new NP, I would rather get mentored by a seasoned NP than a physician, any day.

      With all of these disagreements back and forth, we tend to lose sight of the ultimate goal of healthcare, which is to take care of our patients and improve their quality of life. This goal should be shared between physicians and nurses, alike. We should be able to find a common ground and work together for the best interest of the patient.

  5. Mary M says:

    This is being done because it cheaper to hire NPs and PA than physicians. I have 4 years of college, 2 years of graduate school and 4 years of medical school, followed by 4 years of residency, which is much more than what the NP or PA has. I have worked with some excellent NPs and PAs, yet they are under the supervision of a physician. I think if this is allowed to be passed, then you can forget getting hired if you are a physician in the VA. It is purely a money saving ploy, that is not in the best interest of the patient.

    • Kevin B says:

      There is no doubt that the physician is the top pentacle clinical position in providing advanced patient care. That being said the NP is not designed to out do the physician but to reduce the strains on the healthcare system. As an NP I have had 12 years experience as a nurse, four years of undergraduate nursing education, three years of graduate nursing education and going through an additional four years of doctoral nursing education. Patients should not have to wait to see a provider. APRN’s as licensed independent providers will be able to practice to the fullest level of their education, experience and training without formal supervision from their physician colleagues. Our education and knowledge allows us to do what nurses have been doing since our beginnings and that is to take care of our patients and to know when the advanced knowledge of the Physician should be accessed . No healthcare system can survive without having Physicians or Nurses on staff any statement to the contrary is inflammatory and just not true.

      • Dale, BSN, SNP says:

        Very well said. Thank you.

      • John says:

        Without an extensive knowledge of physiology which includes having years of education in biology, physics, chemistry and genetics. The idea that a person can memorize the signs and symptoms of every know disease and when to tell when a disease is progressing or if you have made an incorrect diagnosis is impossible. Coming from being a teaching assistant to nursing students for their sciences, the science education is not there. The public health students had more science education. If NP’s would like to practice independently then I would like to see them take the same board exam as the physicians, if they match up then okay, otherwise they should practice under physician oversight.

        • Rebecca says:

          Nurse practitioners are not educated to treat every single specialty within every population. There is no way they could ever take the same test because nurse practitioner education is directed to one specific population. I’ve almost completed my doctoral degree as an adult and geriatric nurse practitioner, so I specifically learned to evaluate, diagnose, and treat complex and acute illnesses in older adults. Just like in any team setting, if you don’t know the answer you ask for help. I’ve seen physicians consult with each other, just as is appropriate with nurse practitioners when they need help. Allowing nurse practitioners to practice independently doesn’t mean they will neglect the rest of the medical community and never ask for help from physician colleagues. It means that patients don’t have to wait for cosigning of orders from a physician when a nurse practitioner is fully capable of autonomously preforming the act. All healthcare is about teamwork, it’s about breaking down barriers for the patients that need our help.

        • Rene says:

          If we take the same board exam as the physicians and we pass the exam will be also be permitted to put MD or DO behind our name as credentials? If the purpose of a board exam is to assess critical knowledge required of a particular profession, then we APRNs who passed the physician board exam should also have earned the right to place MD or DO behind our name as credentials. Correct?

    • Kelli, NP says:

      This is a ridiculous argument. Do you feel you need someone trained for a few weeks in every single medical specialty to provide your primary care? Or perhaps someone who has spent 2-3 years in primary care training only? By your logic, we all need electrical engineers to change our light bulbs. Physicians have become over-trained and over-specialized. Medical schools are realizing this and making changes in their curricula. NPs are perfectly capable of providing quality primary care. Read the research on the subject and try to put aside your biases. There is plenty of room in the health care arena for a variety of providers who will help patients access quality health care for reasonable costs. And NPs are perfectly capable of operating independently; they already do in several states, and quite successfully, I might add.

    • slu2 says:

      If we are going to talk about the amount of education one has as being what makes an MD more qualified than an NP, how about this: I too have a 4 year degree, a master’s degree and practice for 8 years as a LCSW. I also have a second bachelor’s degree in nursing, 5 years practice as an ICU Rn, a master’s degree in nursing and am now finishing my doctorate. I have been working the last 3 years as an APRN. In the end equal amounts of education more years of direct practice with patients. Who is more prepared or the better provider? Both are equally effective and provide safe care. Someone earlier in this thread pointed out that there are bad MD’s and bad NP’s. It comes down to this, nursing and NP education is different from that of the MD. One is not not necessarily better than the other. As providers of healthcare it is our responsibility to provide safe quality care. NP’ are responsible for the same medical knowledge as MD’s. Research demonstrates that care provided by an MD (let me preface this by stating I am not talking about specialties such as surgery, but primary care, women’s health, psychiatry, etc) is equal to the level of care provided by an MD. You should jot worry about finding a job, even at the VA. There is enough work for everyone.

    • Beverly Benmoussa, MSN, APRN, FNP-BC says:

      Yes, more does not equal better. Read the following commentary by David Gorski, MD, PhD as he details the current evidence base surrounding full practice authority for Nurse Practitioners as well as the desperate voice of the fading physician opposition.


    • Joanne says:

      Mary, I am not an MD. I would wait for 2 hours to see you rather than see an NP within 15 minutes from entering the office.

  6. Cynthia E. Williams says:

    I am an Adult Nurse Practitioner with approx 17yrs of deversified experience. I believe that “independent practice” is right direction Veterans Medicine. NP’s do not practice out of there scope. If we aren’t sure we will ask for help, refer or consult with a physician. Is that any different then what physicans do. Only a fool thinks he knows it all.
    We are Advance Practice Nureses, many of us have doctorates of clinical practice. We have proven our selves time after time. Why continue to hold us back
    Veterans need healthcare and who better to care for them then Nurse Practitioners. We are taught from novice to expert to look at the total patient;”mind, body and soul”. Many of our veterans have both physical and mental issues. Total care delivered by the total care providers Nurse Practtitioners

  7. Emma Krock says:

    I have been an APRN for 30 years.This has been a great experience for my patients and families.I was encouraged by one of the best Pediatricians I know to start on this path..I encourage you to make this available to families in your area..It is a win ,win for all!

  8. Audricia Brooks says:

    Advanced Practiced Nurses (APN’s) in Ambulatory Care settings must meet the same clinical standards as their Physician (MD) counterparts in disease prevention and health promotion. The PACT Team Model of care is designed to be patiented centered. APN’s have demonstrated proficiency in patient centered disease prevention and health promotion. Being a diagnostician is a bonus for APN’s and MD’s. But both groups are well equipped to meet this requirement

    • Joanne says:

      I don’t really trust anyone who pats themselves on the backs too much. That leads to mistakes. The “my patients”, “I’m a good NP” etc …. it’s not climbing a ladder to respect. As a patient, I want to see an MD and not a practitioner with an alphabet added to their names. The MD devotes years to the science (I’m repeating), the NP normally is an RN that gradually moves forward. Yes, the patient care background is there, and any skills can be picked up, but at the end of the day, it’s the Doc who’s the scientist – the diagnostician, and he/she is the one I want to see.

      • John says:

        Agree, as a veteran I like to think this country can give me the healthcare from a physician and not a nurse. The day I see a nurse sit down and take the identical exam as a physician and pass it, maybe.

  9. Terry Clark says:

    NP’s lack the in depth basic medical education. I know, I have taught some classes to graduate nurses. They have only observed a few cadaver presentation, never disected one. They do not have the skills or mind set to be independent practitioners. Their advanced degrees are mainly focused on completition of their research and the paper they write, not on clinical skills.

    • Fredi says:

      As an APRN, I have completed gross anatomy with advanced dissection, and my classes, residency, and internships were all focused on clinical practice, not research. I realize that currently education varies widely from one institution to another, but the assertions made are not correct across the board. I’ve owned and operated my own practice for years and have an excellent reputation in patient care in the community.

    • J says:

      There are APRNs who have dissected cadavers during their education, but way to make generalizations.

    • Amy says:

      Your statements prove that though you claim to be expert on what care a nurse practitioner provides, you do not know what you are talking about. A nurse can obtain a PhD to complete research, but I am obtaining my DNP, Doctorate of Nursing Practice, which is most certainly clinically and systems based. NPs are not specializing in GI or cardiology. We specialize in care of the family on a general basis, acute care with more in-depth education on advanced skills, etc. Therefore, we do not waste time going through a clinical rotation in the NICU when we will never be caring for those patients. We spend more time learning about the patients for which we are caring. More classes in school does not mean you are more adept at your job. I was required to take Music Appreciation in college, but I’m no expert on Baroque music…

      • John says:

        So how do you learn respiratory physiology to take care of an asthma patient without ever taken years of biology, chemistry and physics? A physician with this science background wouldn’t send a stand asthma patient to a pulmonologist to interpret their spirogram while NP’s can’t explain the physics or biology of it to perform the interpretation. I worked as a paramedic for years and regularly went to practices where NP’s would request patients be sent to the hospital because they didn’t understand complex physiology.

    • Kelli, NP says:

      Tell that to the thousands of NPs in this country who are very successfully operating independent practices. Not to mention the states where collaborative agreements with physicians are required, yet are strictly formalities. The research of outcomes in NP practices fails to support your anecdotal argument. My advanced degree was not about research papers. Search any college NP program and you will see the rigorous clinical focus in each specialty. NP students are required to be registered nurses with a 4 year degree before they are admitted.

    • slu2 says:

      In receiving my nursing education I was not required to dissect a human cadaver but was responsible for knowing that information. I have to say it was more beneficial for me to actually be at the bedside as an RN working with real working bodies and systems. Knowing how to actually care for, let’s say a 3 year old with an open chest post-op who happened to be connected to a Centimag ventricular assist device and a ventilator (oh yeah, who is also in kidney failure and on CVVH) and understanding the anatomy and physiology of that just as valuable as dissecting a cadaver in med school. I am currently a psychiatric NP. It was interesting the other day on my unit when one of the patient’s was on the floor unconscious and gray I, the NP, not the psychiatrist MD, was the one who led the resuscitation of the patient while the MD stood there with a shocked look on his face. The MD later stated he was thankful I was there because in med school and residency he had never actually physically done CPR on a real body.

    • Beverly Benmoussa, MSN, APRN, FNP-BC says:

      Invalid. I do not want a nurse practitioner to perform cardiac surgery on me, but to that end, I do not want a cardiac surgeon to perform my annual PAP. Many physicians have a longer education (some do not), but they do not necessarily have more knowledge of the core aspects of primary care. This is the view of the National Institute of Medicine (the definitive word on medical practice in America).

  10. Enyo says:

    This discussion is very interesting because if you live in northern virginia and you go right across the border to Washington DC, you would discover that DC law allows the NP to practice without restrictions. NPs have independent practices in DC and statistics indicate that they are doing an excellent job. There is a place for the MD as well as the NP especially in primary care. NPs are not trying to be doctors but want to address the complete needs of their patients. Complicated cases will be referred to the MD with more training. NPs will work within their scope and refer to the MD if necessary. This is a win win situation. There are other states that allow NP practice without restrictions and this is serving the populations well. This is definitely the way forward, medicine is changing.

  11. Joann Sumner says:

    This discussion points out the arbitrary way NP’s are governed, depending on where they reside. Every state is working towards independent practice for APRN’s, and because some states have it and others do not, some NP’s move to take advantage of being able to work independently, which means we are able to collect more of the payment for our services rendered. This is a financial and power issue, not a safety issue. NP’s know well how to collaborate and refer, and we are not attempting to be MD’s, just work along side within scope of practice. Please let us have regulations that are national in scope, like our RN licensure currently is, making transferring to another state very easy. This is to our patients’ advantage.

    • David Guinn FNP-BC says:

      Allowing APRNs to practice independently would benefit the people of North Carolina. This is a legislative goal of the NC Nurses Association and parallels the recommendations of the IOM and the AARP. Our present restrictions discourage innovative healthcare, restricts provider supply, and raises costs. Instead, APRNs should be empowered to fully practice to the extent of their education and training. Patients would be the biggest winner under such a reform.

  12. John Schiller says:

    As a newly retired veteran of Desert Storm/Shield, Enduring Freedom, Iraqi Freedom, Joint Forge, etc, etc and an infrequent patient and customer of the VA healthcare system I can honestly say that I have had more than my share of horrible/frustrating experiences with this system. My point being, how much worse could this system get by allowing NP’s more flexibility in their practice.

    That being said, I am also a 15 year Registered Nurse finishing my first semester in an Advanced Practice RN program and can honestly say that I have NO PROBLEM collaborating with an MD in making diagnosis. I don’t understand, and it just doesn’t make sense to me, the infatuation APRNs have with seeking autonomy from MDs. Other than a power play feeding insecurities, it doesn’t make sense to me that a graduate of a 2 year master’s program could compare their abilities to that of residency trained MDs. Doesn’t make sense to me and with what I know; the mistakes I’ve seen and done, scares me a little. Once I’ve graduated, I’ll have NO problem collaborating with an MD so I can pick their brains and learn from their experience and training. My ego can handle it.

    • Eva Francis, RN, BSN says:

      Very well stated!. I too, am perusing my NP and feel it is without question necessary to have a physician to collaborate with. I will have no problem asking for assistance. My ego is well in check! There is no comparison in a Master’s level trained NP and a well trained residency completed M.D.. I do feel like there is an opportunity for Physicians to learn from nurses as well. There must be mutual respect from all perspectives.

      • Ellen Blevins, RN says:

        Collaboration is what APRNs do, being forced to have a written collaboration is what is wrong. Physicians in my state are charging for this “privilege”. One is billing the APRN $15,000/yr and $250/hr to review 4 charts 3 times a year. He does not see the patients nor is even in the same town. But if the APRN looses this written agreement due to the physician relocating, becoming ill or dying the clinic must close if there is not another agreement. How does that serve the public? It doesn’t.
        The quote about working in silos is so tiresome it’s not even acknowledged any more. APRNs do NOT work in silos. They engage in true collaboration, consulting when needed with specialist or a physician.

        • Lori G says:

          I completely agree. Working independent does not mean alone, it means to not have restrictions of practice. There is no way any health care provider can provide for all patient needs in an “independent practice”. You consult, collaborate and refer but have the ability to practice within the scope of your knowledge. This is not a “pissing match” and it isn’t about ego’s. It is about providing the needed care to patients that is uniform and consistent regardless of location of clinic.

        • BOB says:

          So you want to physician to “collaborate” with you (teach, advise, assume some of the patient responsibility, and the associated risks) for free. God it. While you put in two years of your time and want to be seen as “equal.” Maybe pitch in to paying back medical student loans and then physicians will willingly teach you and assist you for free. Keep fighting for full independence, more and more physicians are unwilling to teach APRNs and that trend will just get worse. Then the data will speak for itself and you will have to go to medical school once again to play doctor.

      • Jamila Fox says:

        You are only saying this because you have no experience, you are new in the career, you are scared and you are nervous. If your opinion is the same 5 years after you are in the field then I will accept your opinion.

    • Karen B says:

      Practicing independently does not mean Nurse Practitioners no longer collaborate with our physician colleagues. I am in a state where I am able to practice independently; for my patients, this means they can walk out of an appointment with me with the prescriptions and treatments they need without delays while seeking approval from my busy physician colleagues. I recognize the strengths and limitations of my education, and one of my strengths is recognizing when my patient needs more than I can provide. Nurse Practitioners who practice independently do not practice in isolation! One of the strengths of nurses is our ability to work collaboratively as part of an interdisciplinary team.

    • Jane R says:

      I agree with you. I also think educational institutions are driving nurses to get more and more “letters to plop behind their names” as a way to make more money for the schools. I notice that even RNs who have a BSN somehow think adding that after RN means something more. It us all the same license, kids. Also, there is no way a nurse can replicate the hundreds of hours of expertise Mds attain with an NP. Yes, there are bad doctors out there, but there are a lot of egotistical RNs out there withe hunger for power, instead of humility for not having all the answers.

      • Ellen Blevins, RN says:

        The placement of BSN, RN is not bragging or egotistical. It’s called etiquette, the proper placement of earned degrees after the name. Would you disparage a physician for placing MD after his or her name? Or a college professor for the PHD? Nurses with associate degrees are often referred to as RN with advanced degrees added.
        Nursing is different from medicine. Nurses are taught the nursing process and are more incline to treat the entire patient not just the disease or symptom. I work with APRNs and not one wants to practice without back up. This does not mean a forced written collaboration but a professional exchange.
        And yes the Future of Nursing by the IOM recommends nurses engage in life long learning. This not only means keeping up with required continuing education(CEs) but by advancing degrees that allows the nurse to follow his/her preferences in education and provide the best care possible.

    • Casey V Fowler says:

      I felt this way before I graduated, but you may find that you opinion changes when you graduate and you discover what you are capable of.

    • J says:

      As a student, you should absolutely be collaborating with someone with more experience to make diagnoses. As an APRN myself, I would even make an argument for APRNs in their first 2 or so years of practice to have some sort of collaborative agreement, either with a physician or a more experienced nurse practitioner- but, once you’ve been at it for a while, you’re going to be able to make diagnoses in your scope of practice without help. Having to have someone involved at every step of the way seriously impairs your ability to care for your patients. Can you imagine if every time you see someone with an ear infection, you have to go grab a physician before you can prescribe antibiotics?

      Even in the case when the collaborative agreement is really more of a formality- once you’ve been doing it for a while, you don’t need to run to someone every time you see someone. You should be striving to increase your knowledge throughout your lifetime, but that doesn’t mean you need a formal, legal agreement to do so. But that formal, legal agreement gives physicians an easy way to make money off of you, when they would have the same discussion with their physician colleagues for free (and yes, even physicians need to pick each other’s brains from time to time. No one should practice in a vacuum).

    • Julie Hannah, FNP-C says:

      New grads need to collaborate closely, but you do a disservice to veteran NPS with 10+ years experience who no longer need hand-holding by saying that all NPs should be supervised by physicians. I have been an NP for 13 years and it is not ego but fact to say at this point I know as much as an family practice MD. At this point in my career, physician collaboration is just a way for MDs to keep me as a low-paid employee instead of an effective competitor. Read the below post about the NP who pays an MD $15,000/yr needlessly just so she can have her own practice in a restrictive state – I have colleagues who are forced to pay this “tribute” to MDs, and it needs to stop. So shut your ignorant, don’t even have a degree yet mouth before you destroy your own professional future!

    • Carol E says:

      Hi John,

      Save your comments for about 5 years and then re-read them. Let’s see if you agree with what you have written once you’ve practiced for a while. You might be singing a different tune.

      While I have no doubt that some APRNs are on an ego trip, that phenomena is not limited to APRNs.

      I cannot believe how rediculous this discussion is, when we are about to see millions of people entering healthcare systems due to the Affordable Care Act. There is so much work to be done! I value every one of my colleagues and feel our skills are needed from every one of us.

      • Veroncia Guardado, MSN, APRN, FNP-c, DNP student says:

        Well said Carol. I was thinking the same. It won’t be long until John realizes what he said.

  13. Karen B says:

    I would like to know if the MDs who feel threatened about Nurse Practitioners being able to practice independently have had the opportunity to work collaboratively with them. I am a Nurse Practitioner with the ability to practice independently in Washington State. I have never once claimed to be a doctor. I am able to appropriately diagnose and manage complex diseases, and recognize when it is important to collaborate and refer to my physician colleagues. The focus of this discussion should be the best way to provide patients safe, timely medical care. Nurse Practitioners who can see patients independently and prescribe them the appropriate medications and treatments are an important component in the team approach needed to provide veterans (and all patients) quality health care.

    • EP, APRN says:

      I was a medical surgical, NICU, L&D, helicopter life flight, adult ICU, and psychiatric nurse for 25 years before I went back to get my advanced practice degree. In CT, I have a collaborating Doc, whom I pay to be available to me. I have called him twice for advice.
      I’ve had a private psychiatric practice for 10 years and all of my referrals come from area physicians of various specialties. I collaborate with them and specialists as needed, regarding the patients they ask me to see. My direct competition, the area psychiatrists, are not happy that I practice on my own.
      I have no objection working with a physician when we acknowledge and respect our respective areas of expertise; e.g., Nurses have long served as patient educators as well as practitioners. But what I see is that physicians want to hire APRNs as their employees. The expectation is that the APRN sees four patients or more in an hour, for $400-800 or more in billable revenue, and the physician practice will pay $50 an hour for the APRN’s time and talent.
      Hospitals are now doing the same. With the current health care debacle, APRNs are being pushed into serving as GPs, assuming the role of PCP and MDs will either supervise many APRNs, specialize further in order to continue to be paid the monies that they always been able to command, or to work for a healthcare organization who will take over their overhead, manage their billing, and pay their benefits.
      The big university hospitals here in the Northeast are buying up all the physician practices, now making the physicians and their APRNs both employees.
      The only ones really profiting for any of this is the big healthcare organizations and the educational systems pushing all of us to go to school longer, incur more debt, and earn less.
      Early retirement is starting to look very attractive.
      P.S. The comment below is a repeat- oops!

    • BOB says:

      I don’t think physicians feel threatened. It is more appalled that someone is willing to spend just 1-3 years on an advanced degree and want the exact same responsibility as a physician. These are people’s lives. Antibiotic resistance is real. Narcotic abuse is real. Even medications that seemingly have few side effects can still do harm. There is always a role for physicians. The pendulum may swing for a while, and those that can’t afford care may be subject to not having the ability to see physicians but those that can afford it will choose a physician. It’s just appalling because when you willingly take on the responsibility to care for others, why would you want to take a short cut to get there? Money? Power? Ego? It’s a facade, though. It is time to start educating the public on the differences in training between physicians and nurse practitioners. Most will choose a physician and not a provider who obtained a degree online. Online. appalling. There are lives people! Not make believe on the playground!

  14. Teresa says:

    i agree that nurse practitioners should be able to write prescriptions since we see them more than you do the doctor anyway. why would you wait if you are in severe pain for a doctor to sign when the practitioner is right there

  15. Heather says:

    As a current BSN nursing student, I am very disappointed to see APRNs being held back by these archaic and physician-focused ideals. I intend to become an APRN, and seeing articles like this is very discouraging. APRNs should be allowed to practice to the full extent of their education and training.

  16. Anne Scharnhorst says:

    IOM recommends allowing nurses to practice to the full extent if their training; so let them.

  17. EP, APRN says:

    I was a medical surgical, NICU, L&D, helicopter life flight, adult ICU, and psychiatric nurse for 25 years before I went back to get my advanced practice degree. In CT, I have a collaborating Doc, whom I pay to be available to me. I have called him twice for advice.
    I’ve had a private psychiatric practice for 10 years and all of my referrals come from area physicians of various specialties. I collaborate with them and other specialists as needed, regarding the patients they ask me to see. My direct competition, the area psychiatrists, are not happy that I practice on my own.
    I have no objection working with a physician partner when we acknowledge and respect our respective areas of expertise; Nurses have long served as patient educators as well as practitioners.
    But what I see is that physicians want to hire APRNs as their employees. The expectation is that the APRN sees four patients in an hour, for $400-800 or more in billable revenue, and the physician practice will pay $50 an hour for the APRN’s time and talent.
    Hospitals do the same. With the current health care debacle, APRNs are being pushed into serving as GPs, assuming the role of PCP and MDs will either be expected to supervise many APRNs, specialize further in order to warrant the pay that they always been able to command. or to work for a healthcare organization who will take over their overhead, manage their billing, andI was a medical surgical, NICU, L&D, helicopter life flight, adult ICU, and psychiatric nurse for 25 years before I went back to get my advanced practice degree. In CT, I have a collaborating Doc, whom I pay to be available to me. I have called him twice for advice.
    I’ve had a private psychiatric practice for 10 years and all of my referrals come from area physicians of various specialties. I collaborate with them and specialists as needed, regarding the patients they ask me to see. My direct competition, the area psychiatrists, are not happy that I practice on my own.
    I have no objection working with a physician when we acknowledge and respect our respective areas of expertise e.g., Nurses have long served as patient educators as well as practitioners. But what I see is that physicians want to hire APRNs as their employees. The expectation is that the APRN sees four patients or more in an hour, for $400-800 or more in billable revenue, and the physician practice will pay $50 an hour for the APRN’s time and talent.
    Hospitals are now doing the same to physicians. With the current health care debacle, APRNs are being pushed into serving as GPs, assuming the role of PCP and MDs will either have to supervise many APRNs, specialize further in order to continue reaping the pay that they always been able to command, or to work for a healthcare organization who will take over their overhead, manage their billing, and pay their benefits.
    The big university hospitals here in the Northeast are buying up all the physician practices, now making the physicians and their APRNs both employees.
    The only ones really profiting for any of this is the big healthcare organizations (hospitals, HMOs) and the educational systems pushing all of us to go to school longer, incur more debt, and earn less.
    Very early retirement is starting to look very attractive.

  18. Jose O says:

    I believe if the proper training is provided to APRN’s to practice in a matter that patient’s safety is at the forefront, then they should be allowed that right to practice. APRN’s programs do educate nurses for this advanced responsibility. This is taken very seriously by most APRN’s I have encontered. I believe much of the opposition is a Turf battle in the business of healthcare. This is shameful.Patients should be given the choice.

  19. Linda Patterson, RN says:

    In Washington State ARNP’s have independent practice. We have not seen a decrease in the level of care provided. If the ARNP has a question they refer to the MD. For most care they can and do provide efficient, cost effective, excellent care. Restricting their license is crazy. with the affordable care act they need to practice to the full extent of their license. Most “doctors” are going to specialist practice to pay off their student loans. We have a shortage of family doctors in our state and ARNP’s are filling in the gaps. What is a patient suppose to do if they don’t and can’t find a MD?

  20. Dr Kim Kuebler says:

    The IOM endorses and supports the advanced practice nursing role – is this a geographical issue – it is not a Fedeal issue – Clinical practice is collaboration and all providers have a place to support optimal patient outcomes

  21. Casey V Fowler, MSN, NP-C, ARNP says:

    I find it interesting that opposing views from physician organizations were given a voice in this aricle, but no input from APRN’s was included.

  22. vic says:

    Patient outcome is the acid test. It has never been proven that MD’s provide “better” care than NP’s. That has been studied, analyzed and processed ad nauseum. FOr the vast majority of conditions a patient goes to for medical help, they absolutely do not need a physician with 8 years of training. Medicine is not the exotic science it once was 250 years ago. Most of it is bread and butter. The person who will be your best provider is the one who listens the most, takes time to assess the whole picture, has the most experience, has seen the most cases and knows how to access the copious online help if they are stymied. And any provider… NP or MD who is stumped bumps it up to a specialist. That is what

    Like it or not, NP’s are the wave of the future and may be our ticket out of the dismal state of our healthcare system and our health, in general.

  23. John F says:

    Nurse Practitioners are well educated to care for patients with complex and acute medical problems. I work providing care as a hospitalist and the level of supervision I get is minimal. I along with the patient determine the plan of care. If I’m unsure of how to care for certain medical condition, I consult or at least discuss the case with the specific service. Having barriers to care only limits the quality of care patients receive. Regulation and practice standards should be based on available data and not on the opinions of certain group. Physicians have long argued that independent NP practice will lead to a lower level of care, this is unfounded. Again, the VA should decide based on the data.

  24. sherri says:

    NP’s have been LIP’s in the military for as long as I remember. This is nothing new to the Federal Government.

  25. Dr. J Anderson, DNP, NP, ANP-BC, CNE says:

    Thanks to US Medicine for the opportunity to exchange expert opinions about the idea of the VA designating all advanced practice RNs (CNM. CRNA, NP and CNS) as independent practitioners. As noted by others, State Boards of Nursing oversee their state licensing requirements and national efforts have been underway for years to enable independent APRN practice in all states. However, those APRNs who are allowed to practice independently under their state licensure, may be prevented from doing so by barriers at any of the VA/VHA levels. These barriers include policies, attitudes, and beliefs, many examples of which are shared here.

    Although expert opinions about the differences between APRN and physician qualifications, educational preparation, and the quality, safety, efficacy, and efficiency of the care they provide are informative, opinions are the lowest level of evidence. Extensive Level 1 evidence (systematic reviews and meta-analyses) over the past 40+ years have demonstrated, at the least, equivalency between physicians and APRNs in patient care, outcomes, satisfaction, and health services utilization (1, 2, 3). NPs have outperformed physicians in patient satisfaction, follow-up care, and cost-effectiveness, both inpt and outpt.

    Given the extensive high quality evidence to support independent APRN practice, the VA is taking a leadership role, through this initiative to remove barriers to advance practice nursing at the full scope of education and licensure, to meet the need for both access to safe, high quality care and effective and efficient use of limited federal healthcare resources.

    Full disclosure: RN 35 years; Adult NP 25 years; DNP 3 years; VHA PC NP 7 years; military veteran.

    1. AANP. (2013). NP Cost-Effectiveness. Retrieved from http://www.aanp.org/images/documents/publications/costeffectiveness.pdf

    2. AANP. (2013).Quality of NP Practice. Retrieved from http://www.aanp.org/images/documents/publications/qualityofpractice.pdf
    3. RW Johnson Foundation. (2011). Quality of Care Provided by Advanced Practice Registered Nurses. Retrieved from http://www.thefutureofnursing.org/sites/default/files/Quality%20of%20Care%20Provided%20by%20Advanced%20Practice%20Registered%20Nurses_0.pdf

  26. Sheryl Teachenor PMHNP-BC says:

    I vote yes

  27. Carolyn says:

    APRNs are a vital part of our health care system and their use should be extended, not restricted.

  28. Carlos Feliciano says:

    I am a nurse in Florida. I have worked closely with ARNPs, physicians and residents. The one story that most makes the argument for the ARNPs to be able to have an independent practitioner happen at a nursing home in 2008. I took a job as an assistant Director of Nursing at a nursing home. We had a 33 year old type 1 diabetic, who was labeled non-compliant. From the moment I saw her, she looked like the poster child for Cushing’s syndrome. I spoke to the attending MD and clinical Director, but nothing. I spoke with the NP, and after some resistance, the NP gave the patient the benefit of the doubt. The NP ordered some lab work, and the results were consistent with the diagnosis of Cushing’s syndrome, but neither of the four endocrinologist in town listened. 3 years later, and one month before the patient’s death, the patient was hospitalized for renal failure. As one of the attending doctors came to see her, the patient next to our patient told the doctor that my patient looked a lot like her and that she Cushing’s as well. The doctor ordered the required tests and our patient was diagnosed with Cushing’s. Unfortunately, it was too late and sent to the nursing home to die, under hospice care. I received a phone call from a friend, who still worked at the nursing home, telling me that the patient asked for me. As soon as got to the nursing home, she gave me a hug and asked me,”Guess what? I replied and she said, as her eyes filled with tears,” You were right! I have Cushing’s. I was overwhelmed by every emotion in the book. You see, I was then enrolled in the Geriatrics NP program. Had she been my patient, she would have lived to see her grandson born. I would have never given up on her, because as a nurse, and unlike her doctors, I didn’t let my empirical observations be clouded by my biases, as the four endocrinologists did!

  29. Heather J says:

    This model of advanced practice nurses being independent practitioners practicing to their full scope of practice works very well for the military and should for the VA, too. This is an old debate that has already been answered.

  30. Larry Wilson says:

    Deploying Advanced-Practice Nurses as a solution to the shortage of money and providers is an excellent idea in concept.

    It’s a questionable idea in reality, primarily because of the issue of education.
    Some have reported that they attended cadaver lab as part of their NP education; that’s dandy, but it’s not a standard of education in nursing, meaning every physician has had their hands on a cadaver, whereas we just can’t be sure if the NP has ever even seen a dissected body part. We also know that every physician has completed a residency, whereas no residency or fellowship is required for NP practice…which is a ridiculous notion; every NP should be required to attend a residency of at least one year.

    I’m not beating the medicine drum; I am an RN with 12 years of experience, currently at the half-way point of completing an NP program, a program that has largely been irrelevant nonsense taught by lazy and uninformed instructors. I want to be a proud and empowered independent provider, but nursing is setting us up for failure on a wholesale level. I’ve spent copious amounts of time in multiple classes dealing with the ongoing idiocy of “nursing theory,” participated in so many “team-building” assignments that I’ve started to wonder if there are going to be several other names on my diploma, and silently screamed inside as my classroom “peers” argued about ICD-9 codes.

    I’m living it; NP education is fragmented, weak in sciences and solid clinical experiences, and hanging on to too many of the useless components of nursing theory and language that are incompatible with communicating with anyone else on the healthcare team. We have an ideal opportunity, even an obligation to build up our foundation, but until we realize that we are like Dumb and Dumber driving our dog-van across country to deliver a briefcase, we will find our only success will come in spite of ourselves, not because of ourselves. We are literally only gaining any relevance because we are falling into a vacuum where who we are “sounds like” what might be the solution. We need to get our feces consolidated, because when medicine realizes that we are going to move into their space like invasive oriental carp, they may just release the reins on Physician Assistants, who undeniably receive a higher quality education than NPs, and we will be left fighting over contract jobs in the prison system.

  31. Rosa Owusu FNP says:

    100% Yes! For Nps to be independent practitioners, especially in primary care. We all know the collaborative agreement is just a piece of paper. I vote yes!

  32. Dr. B. Briscoe, DNP, ACNP-BC, CNS, CEN says:

    Dr. Anderson’s comments and supporting evidence are dead on. As has been eluded to in prior posts, this argument against NP autonomy by physicians is very much financially motivated. I am shocked that some of my ARNP colleagues are not supportive of their own profession. The ARNP argument for independent practice is not an ego issue; it’s a professional one. I am a healthcare professional who knows his scope of practice and has no issue with true collaboration. I’ve been in Nursing for 25 years; 12 of those as an ARNP. As a retired Navy Nurse Practitioner I can attest to the fact that what the VA is attempting has worked well for decades in the military. Let’s face it folks, military nurses (RN and ARNP) have done quite well as not only independent providers but also as Commanding Officers and Executive Officers in small to large hospitals in the U.S., Overseas and in Operational settings. No one specialty knows it all – that includes physicians. In my career I’ve seen just as many detrimental mistakes in patient care by our ‘more educated medical colleagues’ that I have other specialties to include nurses. Collaboration is working together to accomplish the best outcome for our patients. Collaboration is not being forced to have MD’s cosign your notes so they can get a percentage from each patient you see as part of your bonus. Collaboration is not suppressing your colleagues by requiring that the physician’s name be on FMLA forms (although NP’s are authorized to sign them under the Family Medical Leave Act itself). Collaboration is not having the ARNP do all the work regarding Preoperative clearance but also requiring the MD to cosign the preoperative clearance note. I can read an EKG, I can interpret labs. Collaboration IS for lack of a better definition – One Team, One Fight. I most strongly support the move of the VA and hope this trend carries over to the archaic system we have here in Florida.

    • Todd Clow says:

      Concerning the comment made by Doctor B. Briscoe, DNP (redundant),ACNP-BC,CNS,CEN: I think the word you were looking for in your second sentence is ‘ALLUDED’…

  33. Kayleen Clute, CRNP. APRN says:

    I as a APRN. I have been seeing patients in primary care for 19 years and an additional 7 years as a nurse. Along with an undergrad BA,
    nursing program, Masters program and post masters NP program, I have completed a 3 year herbal studies program. This is not bragging
    rights, it is about being open to knowledge and information to help my patients. People are disillusioned with health care.
    What are we going to do to help them?
    I have used a holistic approach to care which has broaden through the last 15 years. I work in collaborative care and an independent practice.
    If I have a question, I have a plethora of colleagues to call. I think the more difficult issues are the declining health of our nation.
    I spend hours discussing health issue that can save the life of my patient and family; from a prevention perspective. I spend just as much time discussing,
    nutrition, healthy eating, supplements, herbs and lifestyle promotion. There are so many people suffering, enough to go around.
    Dont be afraid of change, embrace the challenge and focus on the patient and family in front of you. The VA has many suffering soldiers,
    let the APRN and Physicians continue their work without barriers. Blessings to everyone who takes on this calling.

  34. Sandy says:

    APRN’s of all types provide safe, high-quality care in their given scope of practice. Family NP, Adult NP, Pediatric NP, Geriatric NP, Psychiatric NP. Board certification helps insure the APRN is keeping up with their field of practice, and health care organizations can authorize specific practice privileges to each one, as they do with physicians. A license, educational credentials, board exams, and privileges all tell the public that this person is able to provide health care of a particular type/scope.

    There are NPs who are the head of medical staff in some smaller hospitals in New York state. The physicians voted to put them in that role, because they are excellent clinicians and sometimes, excellent administrators. AANP had one as a keynote speaker two years ago. He was most impressive. He was an NP.

    The IOM report is a sound basis for the VA health system to base this decision.

    As a Family NP for 30 years now, it is my observation that NPs are allowed to care for people when and where there are not enough physicians to do so, and the NPs do a good job of it. In locales and situations where there is a surplus of physicians, then the public is made to fear NP care, by some physician groups. This behavior seems self-serving for the physician. Both can do a good job, with proper education and training. The NP is paid less than the MD, so the NP is often more cost-effective as a provider. Many patients like a holistic approach by their provider, and nurses are educated to do this.

    There are enough people needing care to go around!

    APRN’s are quite capable and they usually know their limits. The VAH and its patients are already getting excellent services from APRN’s – I have met quite a few at conferences and professional organizational meetings. They are all impressive, knowledgeable professionals who are proud to serve our country’s veterans. They feel respected at the VAH system, too, and that matters.

    In my primary care program years ago, taught by MD and NP professors, we were told we could care for 80% of the primary care problems seen in any practice. Our job was also to recognize the 20% of scenarios that needed a higher level of care or an evaluation by a specialist. This has been true. We were trained to be the sole provider at a rural site, with a phone to consult a physician as needed, and an emergency department/local hospital about 2 hours away. With experience, few calls are needed. NPs have provided access to quality care in rural and urban places for many years. We still do!

    The public need not fear. It can be win-win to let NPs in the VAH be independent practitioners who collaborate with other health care providers to get the patient needs met competently, safely, affordably, and in a timely fashion. We are doing it now.

  35. P. Wagner, MSN, NP-C says:

    The argument is a very simple turf war. Physicians are threatened by NP’s, both psychologically and monetarily.

  36. Julie Hannah, FNP-C says:

    What concerns me is that the person who will decide if this ruling goes forth, the VA Undersecretary for Health, is an MD. There is an obvious conflict of interest here. If this is recognized as a turf battle, then it should not be an MD making that call. It doesn’t matter what the public commentary is, if he decides to tow the party line for the AMA. What really scares doctors is that if this goes through, it will PROVE on a national scale that NPs are safe, effective providers without physician oversight.

  37. jackie says:

    Why would anyone be against a professional practicing to the best of their ability ? We spend years learning,in schools & from our patients, hopefully getting better at our jobs the longer we have been at it. the difference in the states dictating at what level a APRN/NP can provide care doesn’t make sense. If they are safe to practice in one state, they should be safe to practice in all states As so many have pointed out, there is enough work to go around for everyone. Speaking as a patient, my preference is for a NP/APRN for my medical care- in my opinion, they seem less rushed to get to the next person, & don’t act like they are doing me a favor by taking a few minutes to talk, & (eghads ! ) hug !

  38. Bill CRNA says:

    There have been multiple studies and articles regarding APRN/CRNA care. The data clearly states that APRN’s provide safe and effective care which is extremely cost effective when compared to physicians. I find it incredible that the AMA and the ASA continue to write letters which ignore the facts with the goal of promoting their own agenda. The agenda to procede with models which are less cost effective, and more restricitive, in an effort to control patient care.

  39. R Cross says:

    Fort Knox, which is a Dept of Defense (DOD) facility gives full prescriptive authority for a Nurse Practitioner functioning as a Primary Care Provider, as a Physician. In the military, Nurse Practitioners function at a very high level and do so quite effectively. If it works for the DOD, why would it not work for the VA?

  40. Sandra McNeil DNP, ACNP-BC, AACC says:

    I work in cardiology, and I know my scope of practice. The funny thing is, I practice autonmously when it suits the physician. Very frustrating!

  41. Wanda Gibson-Scipio, PhD, APRN, BC says:

    The premise of the argument that NP’s want to replace MD’s is often the confusion in this argument. NP’s are well prepared to function within their scope of practice which in some cases overlaps with the MD’s scope of practice, but in other cases is clearly different. This is not unique for the MD/NP professionals but also occurs for many other professional groups with overlapping professional practice. The heart of the issue is the provision of safe quality health care. As stated throughout this discussion there is good evidence that NP’s meet this standard of care.

  42. Chuck Griffis, CRNA, PhD says:

    Reading over the responses and comments thus far, I would like to point out, as many of my nursing colleagues have, that there is more than enough room (big shortage) for all of us, MDs and APRNs to practice side by side and never step on each other toes, but just work together collaboratively to meet the needs of our veterans and all other patients. Sure there are times when I’ll consult with a physician colleague, but they also consult with me—lets give up fighting, and be the team we must become to care for all the patients of the future. We all bring unique and well-demonstrated skills to practice. There are so many peer review studies documenting the high quality (and e–quality to MD) of NP and CRNA care that its ridiculous to debate. AMA, stop it already with the arrogance, fear, and turf fights, and start doing your job to lead physicians into the 21rst Century as equal members of a collaborative health care team faced with monumental challenges that will require all of us working as hard as we can to provide the care. We don’t need your war, you need our help.

  43. Elizabeth Willerup says:

    I have practiced as a registered nurse for 34 years; 23 years as an advanced practice nurse. I am both a CNS and NP, ANCC certified. I hold licenses in states that allow independent or collaborative practice. As a DNP, I follow the IOM recommendations for interprofessional collaboration.

    I do not practice medicine; I practice nursing. Most physicians cannot legally practice nursing unless they hold a nursing license. Professionally, nursing, regardless of advance practice licensure (CNS, NP, etc.) must practice within the parameters of their state licensure which is usually more restrictive than federal guidelines. Peer review should be exactly that, review of practice within the professional discipline.

    If there is ever a question about practice outside of professional licensure, referral can be made to another discipline, e.g., medicine, for consultation or transfer of care. All professions need to clarify practice parameters so that there is an understanding of where there may be overlap of practice. This clarification of practice needs to be articulated to the recipient of care as well.

  44. J.D. Rayl, ACNP CCRN says:

    I know I am weighing in late on this forum but one point I would like to make, and the reason I voted ‘Undecided’, is I do not like to see Federal intervention in what I see as a State practice act issue. Veterans are seen on Federal property by APRNs who may have expanded scope on that property, but any NP who issues a prescription that might be filled at an outside pharmacy would be violating local law in many states. This really complicates the issue, and I don’t think it is acceptable to just say ‘Federal overrides State’ even if it opens up access and makes more jobs for APRNs. I am blessed to work in a state where the Nursing Practice Act is quite favorable to Licensed Independent Practitioner status, however if I lived in a state with physician oversight I would have to live with those restrictions, on VA property or not.

  45. Gregory Rendelman CRNA says:

    I have been a CRNA for 32 years. I have cared for patients across all the medical and surgical spectrums including combat anesthesia with another CRNA. This argument is all about money, plain and simple. We are cheaper and evidence based safe. We are entitiled to our opinions but not entitled to the facts. The facts have proven in every study that has been done that APN’s provide safe and compassionate care. I am asked by surgeons to provide anesthesia on their own family members, because they know the truth. I see patients preop on a weekly basis and know how to dial the phone for consultation just like my anesthesiologist counterparts. There are good and bad providers in all fields and that it is where the focus should be.

  46. Erika Trotter says:

    Thoughtful commentary ! I was fascinated by the details ! Does anyone know where my business would be able to get access to a template SC DoR ST-390 document to use ?

Share Your Thoughts