VA: Expanded Role for Advanced Practice Nurses Will Improve Care Access Physician Group Claims That Will ‘Significantly Undermine’ Quality

By Annette M. Boyle

Penny Jensen

Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, the liaison for national APRN policy at the VHA’s Office of Nursing Services.

WASHINGTON—Will granting full practice authority to advanced practice nurses (APRN) help resolve VA’s access issues and improve treatment, or will it instead do a disservice to veterans by moving away from physician-led healthcare delivery?

The answer depends on who is asked.

To expand veteran access to medical services, the VA recently proposed a rule to grant full practice authority to APRNs acting within the scope of their employment in the healthcare system.

The American Medical Association decried the move, saying the “unprecedented proposal” will “significantly undermine the delivery of care within the VA.”

The VA and nurses groups see the situation differently. “We may offer the best healthcare in the nation to our veterans, but that doesn’t help them if they don’t have access because our providers are booked,” said Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, the liaison for national APRN policy at the VHA’s Office of Nursing Services.


Should advanced practice nurses be granted full practice authority at the VA?

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The proposed change appeared in the Federal Register on May 25 and will be open for comments through the 25th of this month. In the first week of the comment period, the proposed rule received more than 10,000 comments.

Despite the intensity of the debate, the change is far from groundbreaking. Currently, 21 states and the District of Columbia grant APRNs full practice authority. Under the proposal, APRNs in the VA would have full practice authority for their work in VA facilities in those states, as well as the other 29.

The proposal “is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing,” said VA Under Secretary for Health David J. Shulkin, MD.

Jensen said she sees other benefits, as well. “Full practice authority would standardize APRN practice throughout VA’s healthcare system and thereby decrease the variability in APRN practice that exists as a result of disparate state practice regulations,” she told U.S. Medicine. “It also would parallel the policies of other federal agencies, such as the Department of Defense and the Indian Health Service, as well as be consistent with the expanding role of APRN practice in the private sector.”

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Comments (25)

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  1. Bob McCormick says:

    Have we asked our Veterans how they feel? They are the people that are being treated and will they feel slighted or in danger by not seeing a physician? As a patient I would want to make a choice depending on the ailment I am being seen for.

  2. Viviana Colmegna says:

    In my opinion the level of preparation and experience of an MD can not be replaced with any ARNP degreed that you can compare with.

    Ask yourself Who do I want to treat me….. an ARNP or a MD ( medical Doctor).

    • James Rayl says:

      No scientific study to date has shown that the medical care provided to patients (Veterans or otherwise) by Nurse Practitioners is of less quality than that of a physician. In fact, all studies to date in several different settings have shown the care is at least equivalent.

      I happen to work with physicians (surgeons) who see NPs for their Primary Care. A few of the older Veterans I know request only to see a physician, but when asked it is because they have been misinformed as to the quality of care provided by NPs. Who do I see for my (non-surgical) care? A Nurse Practitioner.

    • Jessica Nishikawa says:

      Hi Viviana,

      I am a nurse practitioner who happens to be married to a physician. If you compare our education II have had 8 years of school (4 undergrad nursing program, 2 masters level np and 2 for the DNP) and my husband has had 8 year of education (4 undergrad and 4 medical school). The difference is that 6 of my 8 years of education were based in patient care since I have a nursing background and 2 of my undergrad years were spent in nursing school. My husband has 4 of 8 years in patient care. The other difference is that physicians, like my husband, complete a residency program after medical school where they learn their specialization. This is a paid, structured, and formalized process. So your question is valid: who would you want to treat you? Certainly if you are in need of reconstructive, cardiac, or brain surgery, you would want a physician who has been formally educated in that area to operate on you. But if you are in need of primary care, nurse practitioners do, and will continue to, provide excellent, evidence based, compassionate care.

    • SMN says:

      SMN. There are shortages of MDs and ARNPs, Physical Therapists and others now. In the entire private sector. And for the really really difficult fields like Neurosurgeons, Opthomologists, and others, it’s just a tough decision for new medical students. They face 4 years of medical school after 4 years of college. Then may face 8 or even 10 years more. The average opthamologist is about 33 to 35 years old before they pass everything and get Board Certified. The Neurosurgeon field is much the same or worse. Brain surgery ain’t easy. And many existing Docs are nearing retirement and some are staying in practice longer than they would like. These people don’t play golf. They get paid a lot but they can’t enjoy the money as much as you might think. When your 18 and looking ahead, 16 years of college and training seems a bit much. The solution ? Academia knows there is a problem. But how to fix this and start reducing the shortages while never reducing the quality of patient care ? That’s a near impossible problem. Maybe it’s not as bad as I think. Maybe I have it all wrong. I would love to be wrong. Hope I am. Just call up the nearest medical school. Ask to talk to an administrator about the number of students and ask about the struggle to get individuals into the fields I mentioned. Where I live, the numbers aren’t there and the costs for individual students is devastating. Problematic ? Hate that word. Works here though. Prayer and less war might help. Wonder which would work better ? I worry a lot. Seen a bit to much maybe.

  3. Audricia Brooks says:

    The literature supports similar outcomes for MD’s and NP’s providing Primary Care. Health promotion, stable chronic disease management and disease prevention are the areas in which NP’s are best utilized.

  4. Steven Zeitzew says:

    There is value and importance to the longer education and training required of a physician which benefits patients in need of a diagnosis, or with complex problems. Once a patient has been diagnosed and there is a plan for treatment an advanced practice nurse can be an excellent choice to help patients manage their problems and maintain health, if following guidelines based on the best available scientific evidence. The failure to fully staff the VA with physicians is a poor justification for expanding the role of nurses. Physicians and Nurses should be supported so they can practice at the top of their license and qualifications. The VA could expand the availability of their current physician staff by providing support staff, and transforming CPRS from the current inefficient software into a system that makes care more efficient and more effective. I value and respect the advanced practice nurses I know and work with, but it would be foolish to pretend they can function as physicians without a physician’s education and training.

    • Gary Seymour says:

      Steven, it appears by your comments you are against expanding the of NP’s in the VA system. While everyone is entitled to an opinion yours is not supported by evidence. It appears that your opinion is largely influenced by the difference in training NP’s have versus that of physicians. Again, as supported by the evidence, length of training in the two compared provider types does not demonstrate a difference in performance of outcomes. Furthermore, many primary care medical programs are updating their educational models to mirror programs similar to that of the well established NP model. It is clear on all analytical and evidenced based measures that the argument of the old physician training model as being the measure of expected outcomes in provider type to be mute.

  5. Rob says:

    Simple fact is ANRP are only having a panel size of 900 in most facilities vs 1200 for MDs/DOs. This means you would need 4 ANRPs to do the same week as a 3 MDs/DOs. Not to mention most ANRPs do not feel comfortable with the same complexity of patients as MD/DO and thus send those patients to the physician. Not apples to apples. Needs a lot of thought before implementing.

    • Gary Seymour says:

      I think that the fact that they are implementing them a 900 vs 1200 demonstrates there has been thought. Limiting their panel size initially will allow for a measured means at working them into the mix.

  6. Hector year says:

    No, while I respect each member of the healthcare team.
    you cannot diminish physicians and elevate APN’s because the experience needed IS not the same.
    unless these persons go to medical school they cannot function replace or compete with physicians. This does improve access but does not improve patient care.

  7. Deb Parrella says:

    Clearly the author has never been cared for by an NP when ill/injured.

  8. Jay Price says:

    Concur with Bob and Viviana completely. To Bobs point we haven’t asked Vets there opinion of this change. The VSOs are not the voices of the Vet! Used to belong to VFW and Legion as a life member but have dropped those memberships as it appears clear their power base is best represented by keeping the status quo. As a Vet who gets his care in the VA; I want a choice and more control of my healthcare. Haven’t we earned that? The only time I have influence in my healthcare in the VA is when I contact my Congresswoman (which I have done several times lately) and amazingly things (access) seems to happen.

    Regarding the question of advanced practice nurses. Really? How far are we going to go before we realize the system is broken? I am already regularly seen by residents, fellows, prescribing pharmacists, non board certified physicians, etc. How far are we going to go in this failed socialized healthcare experiment called the VA? When access continues to be a problem post approval of ARNPs who are we going to approve as physician extenders next?

    The IAVA generation of Vets is not going to tolerate their grandfathers VA.

    • Gary Seymour says:

      Jay, I am a vet. I’ve served both as enlisted and as a officer. I have also worked within the VA system. In addition I am a Nurse Practitioner (NP). I believe I am as qualified to comment on this subject as anyone if not more. I’ve attached some articles that if you take the time to read (which are from excellent and reliable sources), you will find your will be in more than competent hands when treated by a NP. There have been ample studies and research that clearly documents that my fellow veterans will be care for “at least as well” by a physician. Yes, you heard me right. The large volume of research clearly demonstrates the NPs provide as good, and in many areas actually better care than that of their physician counterparts. Don’t take my word for it. If you really care about your health care then read the articles. If you do not believe them web search the same yourself. The good news is that the VA isn’t “expanding” the role of NPs but instead they will be NOT restricting the roles we are trained to fulfill.

      Thanks – Gary Seymour

  9. Julie Bear says:

    We have two issues here: laws and rules regarding scope of practice and patient choice.

    First, the laws regarding legal scope of practice of providers (physicians as well as advanced practice providers) should be based on their formal education, training, and experience. State practice boards have determined that the education and training of advance practice nurses prepares them to effectively practice independently. Rules at individual institutions (public-such as the VA, as well as private organizations) regarding scope of practice should be based on reliable evidence and closely reflect the legal scope of practice already defined. There exists a significant amount of current evidence to support that care delivered by advanced practice nurses is of similar (or perhaps in some areas, better) quality than care given by physicians. Therefore, institutional policies regarding practice authority should be based on these same principles.

    The legal authority to practice to the full extent of education and training should never, however, eliminate patient choice. Whether within the VA or private sectors, patients should have the right to choose their health care provider. They should be able to choose between Dr. A and Dr. B. They should be able to choose between a physician or a nurse practitioner (or other advanced practice nurse). Legal practice authority and patient choice are two separate issues- but both contribute to the improvement of health care.

    Ensuring ALL providers- physician and advance practice nurse alike-are able to practice to the full extent of their education and training improves health care in several ways. It reduces the existing shortage of providers, improving access to care for many underserved populations. Second, it gives patients options for their care, which raises the bar for ALL providers to be their very best.

    So while some may resist the winds of change, current evidence supports that advance practice nurses provide quality care, and support of their full practice authority promotes better health care-from physicians AND advanced practice nurses.

  10. Sherry says:

    Do we really want our Veterans to continue waiting on a physician that never arrives or is days too late? There is a healthcare crisis in our nation and deceased access to care and a shortage of healthcare providers is a significant contributing issue. Nurse Practitioners as well as Physician Assistants are highly educated and trained medical professionals. The care delivered by these providers has been proven in the literature to match the care provided by physicians and in some situations, NP care has surpassed that of physicians. Physicians may have been the only option in the past, however, we are in the here and now of today. Physicians are a necessary and important component of healthcare and in some instances are not replaceable such as cardiothoracic surgery, however, when it comes to primary care, they are not our only option for high quality healthcare.

  11. Ryan Mallo says:

    Patients always have an option, even in the VA, of whom they choose to see. However, for those patients who openly choose a Nurse Practitioner, their care is limited. The VA employees more nurse practitioners than any other system in the world. In 26 states NP’s can practice independently. This is really about moderninzing an antiquated system to bring it up to speed with what over half of the states are already doing. For the other half of the states, they’re moving into the right direction. Further, to Viviana Colmegna the answer is that several major studies show the the outcomes provided to patients by NP’s exceed that or on par with care provided by a MD. So, by all means continue to wait for an appointment with a MD. We need to stop the polarizing MD vs NP debate; we’re on the same team. Your argument is the same argument used when DO’s came to the healthcare team.

    • Ryan Mallo says:

      That should read, “their care is limited by outdated rules and collaborative agreements with physicians…”

  12. Nancy Sweeney says:

    Hundreds of thousands of people already see nurse practitioners in the community for their Primary Care. Nurse practitioners are well equipped to handle the Vault of day today Medical Care, freeing Physicians for more complex cases requiring Advanced testing, Advanced Diagnostics, surgical interventions or more complex treatment. Nurse practitioners work collaboratively with Physicians as a part of the medical team. Studies show that patients are more satisfied with nurse practitioner care in primary settings, because they receive more education about their conditions from nurse practitioners, and their medical outcomes are just as good as those patients who are treated by physicians.

  13. Angie Hays says:

    Nurse Practitioners would give great care to the veterans of this country. They are well educated and spend more time with their patients. I have been taken care of by ARNP and they did a great job.

  14. SMN says:

    ARNPs are accepted just about everywhere in “private” health care. Best care I personally have had was provided by ARNPs. They seem not to be on the same high plateau as the MD egos.
    Could help improve scheduling problems and the seriously awful waiting times at the VA hospitals and clinics.
    Another thing that would help, would be to reduce the number of veteran patients seeking health care.
    War seems to increase patient numbers. Could reduce that. Could help. Save some serious money also. And maybe when funding gets approved for the next war or police action, or attack on those with the mysterious “weapons of mass distruction”, our great federal government elected people could include funding to support all those who go into harms way and suffer the wounds from the fighting.
    Just a thought. Everyone wants peace. Nobody has much. Kinda strange when ya think about it.
    Unless some don’t …. want peace. Our “necessary” strong defense and ENORMOUS military for the USA seems to invite more conflicts. I mean why have the best, biggest military if it is not used. For whatever twisted reason.
    God help us all. Soon would be good.

  15. SMN says:

    The AMA said … “…..would significantly undermine the care …. ”

    That’s incredible ! In my corner of the USA the MDs and DOs LOVE THE ARNPs.
    They love the PACs also. A lot. The are called ” Fantastic Profit Centers ! ”

    Healthcare is a very strange place.

  16. Molly Bradshaw says:

    I am a nurse practitioner and a veteran. I have been fortunate to have incredible support of my medical colleagues. There is clinical evidence to support that the primary care that II provide is equitable, if not better. In private practice if my patients insist on seeing an MD I accommodate their wish. However to deny my care when we are in crisis for providers is ridiculous and outdated thinking. For the AMA to resist is sad— you r only hurting patients because you fail to realize how we can partner… Shame on you!

  17. Mary Goddeyne, ARNP says:

    I worked as a primary care provider taking care of many adults and also all of the Spinal Cord/Multiple Sclerosis/ALS veterans for 6.5 years. All of the ARNPs work independently in primary care. Over my 20 years as an ARNP, rarely did I ever have to seek information or guidance from my collaborative MD. The vets, and non-vets I served were extremely satisfied with my care and expressed regularly it was the best care they had ever had. Plus, I have always been held to the same performance/outcome standards as my physician peers. Many patients have followed me to private practice, as well. As a patient, you always have a choice who you see, e.g. Physician or Nurse Practitioner, unless you’re in a rural area and only one type of provider is available for miles. Now that Florida has new legislation for Nurse Practitioners to have their own controlled substance prescribing privileges (we’ve finally caught up with the rest of the USA), we will be able to run our practices even more efficiently than before. I am glad the VA is finally implementing this, which was in the discussion stages when I left there in 2013.

  18. Deborah says:

    I am an Advanced Registered Nurse Practitioner and I am a provider in a very busy Pulmonary Medicine/Sleep Medicine Practice. My education included 4 years of Undergraduate to obtain a Bachelors of Science in Nursing, 3 years to obtain my Master of Science in Nursing and 2 years to obtain my Doctor of Nursing Practice. In addition , prior to becoming a nurse practitioner ; I worked for 20 years as a Registered Nurse.
    I work in the state of Florida which requires I have a supervising physician. Does he supervise every assessment , diagnosis, treatment plan and prescription I complete? Absolutely not. He is board certified in Internal Medicine , Pulmonary Medicine and in Sleep Medicine. He trusts my expertise, my assessment skills, and whatever treatment I prescribe for the patients I care for.
    My supervising physician is often not in the office when I see patients. If I have a question; of course he is available. On an average, I seek his counsel 1-2 times a month. I see an average 70 patients a week.
    As my supervising physician, he is required to see my patients at least once a year. Many of my patients refuse to see him; not because they do not like him ; but they prefer to see me. My patients trust me. My outcomes compared to my supervising physician are equal or higher. I have never had a malpractice suit, never had a bad patient outcome nor patient complaint.
    I am able to diagnose and treat COPD, Asthma, Pulmonary Fibrosis, Lung Cancer, Obstructive Sleep Apnea, Complex Sleep Apnea, Insomnia, Narcolepsy, REM Behavior Disorder. This is not a complete list but the main diagnosis I evaluate and treat.
    If my supervising physician has a difficult patient with sleep apnea he refers the patient to me.
    The Nursing Model and Medical Model overlap; but nursing approaches an individual patient by not just looking at the body, but also incorporates the mind and spirit. Nurse practitioners spend more time with their patients, seek to connect with them on a personal level and strive to provide the best evidence based healthcare often at less cost; striving to be good stewards of their resources.
    Recently the State of Florida has decided to grant prescribing authority for controlled substances to Nurse Practitioner. It has been long hard fight to obtain this authority. I will tell you in my practice, this will improve patient care. As it stands now, after assessing a patient and determining the patient has a diagnosis in which a narcotic is the treatment of choice, I but the prescription into the electronic medical record, print it off, and then go to my supervising physician and ask him to sign it. My supervising physician never looks at the name on the prescription, what the medication is , nor does he ask why I think the patient needs the medication. But on the days the physician is not in the office, the patient has to wait sometimes up to a week to get their prescription. Requiring a physician’s signature is a formality, does not change the diagnosis or the treatment plan; but only delays the patient from getting the medication they need. I am very aware of substance of abuse, and discuss in detail the potential of physical and psychological dependence with each patient before prescribing a controlled substance. I care deeply for my patients and would never place them danger without careful consideration and involving them in their plan of care.
    Advanced Registered Nurse Practitioners are not just “glorified nurses”; nurse practitioners are highly trained and qualified healthcare providers which are qualified to provide quality evidenced based healthcare and improve access to care.

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