Possible VA Change in Advanced Nursing Roles Sparks Heated Debate

by U.S. Medicine

January 7, 2014

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.


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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.

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