By Annette M. Boyle
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.
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.”
If the 6,400 APRNs already employed by the VA can practice to the full extent of their training and license, it would substantially “expand the pool of healthcare professionals authorized to deliver primary care and other services,” Jensen said, emphasizing that veterans would still have access to physicians when their health issues require it.
APRNs are clinicians with advanced degrees and training who have completed master’s, post-master’s or doctoral degrees. APRNs have four roles: certified nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists. All VA APRNs are required to obtain and maintain current national certification in their areas of practice.
Expanding the role of CRNAs, in particular, has been a hot-button issue. The American Society of Anesthesiologists (ASA) launched the Protect Safe VA Care campaign to block the change, saying it “strongly opposes the inclusion of the surgical/anesthesia setting and nurse anesthetists.” The VA chiefs of Anesthesiology have said that the proposed policy would “directly compromise patient safety and limit our ability to provide quality care to veterans.” Both groups had previously objected to similar changes proposed in House Bill HR1247 last year.
At this time, VA is not seeking any change to VHA policy on the role of CRNAs, Shulkin emphasized in a press release on May 29. The Federal Register notice, however, would give the healthcare system the ability to use CRNAs as it deems appropriate.
Today, CRNAs practice independently in 11 sites. “For all advance practice nurses—nurse practitioners, primary care, etc. VA is basically seeking federal supremacy; to provide us the flexibility, should we need it,” Jensen said.
The flexibility would be extended to individual VAMCs, she pointed out. “If a medical center is located in an area where it’s difficult to hire primary care doctors for mental health, the director may allow full practice authority for nurse practitioners in mental health,” Jensen explained. “But if the medical center already has a strong, well-resourced team that works effectively, the director may not feel the need to make a change—and, personally, I wouldn’t encourage them to do it.”
The proposed expansion of practice authority would allow APRNs in the VA to assess, diagnose, prescribe medications and interpret diagnostic tests to the full extent of their education and abilities without the clinical supervision of a physician. The VA would be allowed to determine elements of the practice for nursing without regard to individual state practice acts, with the exception of prescribing controlled substances.
Speaking for the AMA, the association’s board chairman Stephen R. Permut, MD, JD, said the group “is disappointed by the Department of Veterans Affairs’ (VA) unprecedented proposal to allow advanced practice nurses (APRN) within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law.”
“While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country’s veterans,” Permut said in a statement. “We feel this proposal will significantly undermine the delivery of care within the VA. With over 10,000 hours of education and training, physicians bring tremendous value to the health care team. All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine.”
Some VA physicians also oppose the changes. “The 27-page policy statement just published by the VA will not improve healthcare,” said Samuel Spagnolo, MD, president of the National Association of VA Physician and Dentists. “It will permanently establish a second, lower-level of care in which physicians are not making critical care decisions.”
Nurses’ organizations and some other medical associations have welcomed the change, however. “Improving the VHA’s ability to provide better, faster care to our veterans doesn’t necessarily require increasing budgets or staff,” said American Association of Nurse Anesthetists (AANA) President Juan Quintana. “One solution has been there all along and is as simple as removing bureaucratic barriers to APRNs’ ability to be credentialed and practice to the full extent of their education, training and certification.” The AANA noted that 40 states do not require CRNAs to work under physician supervision in their medical or nursing board statutes.
With the change, the “VA will be able to more effectively meet the health care needs of our nation’s veterans,” said American Nurses Association (ANA) President Pamela Cipriano.
Both groups’ comments echo the recommendations made by the Institute of Medicine in 2011 in its report, The Future of Nursing: Leading Change, Advancing Health, which called for the elimination of “outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”
At the same time, the IoM stressed that some services “clearly should be provided by physicians, who have received more extensive and specialized education and training than APRNs.” Still, it noted that, “given the great need for more affordable health care, nurses should be playing a larger role in the health care system, both in delivering care and in decision making about care.”
A meta-analysis of 19 recent studies in the journal Health Affairs found that nurse practitioners delivered care equivalent “and, in some studies, more effective care among selected measures than that provided by physicians.” Nurse practitioners, who comprise the bulk of APRNs, reliably demonstrated better results for patient follow-up, satisfaction, consultation time, and providing screening, assessment, and counseling, according to the analysis.1
The VA needs more physicians and nurses of all types, noted Jensen. “We’re recruiting for approximately 8,700 registered nurses, so we’re looking to increase our staffing by a little less than 10 percent. I should also mention that we’re also looking to hire another 3,800 doctors.”
- Naylor, Mary D. and Ellen T. Kurtzman. (May 2010). The Role of Nurse Practitioners in Reinventing Primary Care. Health Affairs, 29(5), 893-899.