Should the VA standardize practice across all facilities for nurses with advanced training?

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  1. Freny Vaghaiwalla Mody, MD says:

    Quality and expertise amongst nurse practitioners is too vast to uniformly allow independent license.

    • Randall Sexton, APRN says:

      We’ve also noticed great differences in quality and expertise among physicians, correct? At one point I seriously considered writing a certain school of medicine to ask how in the heck they “unleashed” this individual to inflict such harm on the public.

      • Roy H. Smith, DNP, FNP-BC says:

        lol…. I agree. There are definitely non-quality physicians out there as well as NP’s….yet the physicians all practice without supervision.

        • Julianne Steahr APRN says:

          This is absolutely the case. This “worn out” debate is more about financial gain and control vs practice point. Lets consider the health care climate we are facing and people in need of basic medical care. Primary care is not brain surgery… we refer to specialist when indicated.

        • russ says:

          Yet there hundreds of physicians writing themselves or family members narcotics everyday, getting caught, going to rehab, graduating and getting the privileges back to only get caught again. Let an NP get caught and see if they ever come back to practice. System is perfect for the ones creating/donating to the ones passing laws. Let the providers that want to help, help.

      • Marguerite Burch says:

        I currently work at a VA hospital as a APRN and I can tell you there are many days I leave work and have felt we have done a disservice to some of our veteran population due to the bonehead decisions made by some of the residents and attendings. For example, just the other night we had a “rapid response” on a medical floor. The patient was obviously fluid overloaded with fine crackles bilaterally and no urine output. Creatinine was 2.6 and the patient had on a diaper, no catheter to have accurate urine outputs. Yes, he was a DNR, but when the physician was notified the patient was hypotensive with a mean pressure in the 40′s, the floor nurse was instructed to go ahead and give his beta blockers. He continued to do poorly and when the physician was notified again, the nurse was instructed to give a 500mls NS bolus. These were orders from an attending. Do no harm?? This patient was mis-managed, and though a DNR, he was no designated as hospice.

        • leelee says:

          You make an excellent point. I work in a pretty large teaching hospital in virginia and experience every day the lack of knowledge, and understanding of policy by residents. Seems as though the resident does not know the difference between a DNR and hospice, and he may have missed that hippocratic oath memo. It is sometimes scary the decisions that the attendings leave up to the overly confident yet still incompetent residents.

      • Katherine Darling says:

        Boy, do I understand. I have worked with a few myself. I think if we were truly collaborative, we’d be more humble about what we know and don’t know and quit bluffing.

    • Deb Barton says:

      As it is among physicians, yet they are independent providers. That argument is like a collander. The market decides who to go to for phycians based on qualitiy, they will for NP’s also.

      • Steve Rooney RN says:

        That would be true the consumers had complete access to information.

        The media tell people to “Go see a doctor” not “Go see a health provider appropriate for your needs”.

        The information bias toward physician care is overwhelming, though it is changing slowly.

        The proposed VA change will increase the rate of change.

        • Katherine Darling says:

          I always thought it is interesting the major pharma still promote the allusion that one should always see their “doctor” because that is where everyone gets the best care. I prescribe more antipsychotics than any provider in our region for the seriously mentally ill and have had great outcomes with a great reduction in hosptalizations. The doctor is not “in” because there aren’t enough psychiatrists or PMHNPs. In some places it is not about the providers credentials, it is about there just being “one”. Yet, my practice is so restricted that I can’t provide services as a PMHNP. Medicaid and Medicare will allow for a podiatrist to perform this process. Go figure!

    • Charles Tharp, FNP says:

      As an RN as well as a NP, I believe that the above statement shows some insight as well as some failure to appreciate the ‘defacto’ rules of the road. Practice does vary as Dr. Mody points out. However, my certification as a nurse practitioner, my education and my experience over the last quarter of a century as well as my sense of humor indicates that physicians and nurse practitioners should work together which they can do to the profit of their patients. This change to practice rules will clarify roles and I believe will lessen the liability for collaborative MDs.

      I always refer to physicians when I believe that the patient needs the expertise of a specialist, but find that my patients have appointments with fellow nurse practitioners who specialize in a particular area or even a PA which they are always happy with even when the patient thinks they did such a good job they call them “Doctor”. Usually economic realities, NPs/PAs are cheaper than MDs, control the rules of the road. Personally, I don’t think this will increase our salaries and I don’t think it will increase our status that much. If I were a physician I would feel somewhat different, but wouldn’t change my mind although I am sympathetic about the MDs loss of status and financial reimbursement for their care which has already occurred. Standardization may make more NPs who are used in other roles, case manager and etc., have to do more work as well. So no matter what happens it will be interesting. Schools are already pushing the idea of DNPs, Doctorate of Nursing Practice as the standard for being a NP. Pharmacists, who historically were more esteemed than either nurses or doctors in society, will probably be next to have their roles “enhanced” this way. Will see. PS…I don’t believe that NPs will be doing open heart surgery or transplants in the near future…most doctors won’t have to worry, just the physicians whose practice might be inferior to nurse practitioners. It would be interesting to find out what our fellow RNs think about us…in comparison with physicians that they work with, we already know what patients think.

    • Elizabeth Crooks, DNP, RN, CNE says:

      The evidence doesn’t support this statement. In the past 20 years, multiple randomized trials published in the Annals of Medicine, British Medical Journal, and JAMA (just to name a few) found patient outcomes to be no different based on whether the care was provided by a physician or nurse practitioner. In addition, the curriculum for the education of advanced practice nurses is both rigorous and standardized across the U.S. Prior to entry to practice the APRN must also demonstrate competence by passing a psychometrically valid standardized examination. While the approach to training differs between APRN and MDs, expertise is similar and patient outcomes are equivalent.

    • Betsy Gilbert PhD RN says:

      APRN Education is provided through accredited programs. Certification through a national accreditaion organization is required prior to state licensure. Licensure requirements are more and more consistent. Most variation in expertise is most likely due to experience, professionalism, and other factors that are not about preparation overall. We cannot afford to limit the use of APRNs at a time when health care cannot meet demands for care. Especially for veterans.

    • Casey Fowler, MSN, NP-C, ARNP says:

      According to an article intitled “Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review” published by Nursing Economics in 2011, there are no statistical differences between patient outcomes of Nurse Practitioners and Physicians. In addition, the data in this 18 year longitudinal study shows that patients are more satisfied with the care they recieve from Nurse Practitioners than that of Physicians.

      Nurse Practitioners have established that they are able to perform every task in primary care that a physician can, without supervision, in the states that allow independent practice, so there is no reason for the VA to prevent independent practice in their facilities.

    • Roger says:

      This is the most Uneducated responce I have come accrose. Dr. Mody have you read any of the EBP studies about us (NPs)? In AZ we have been working independently for the last 30 years and in NM as well.
      This has helped the 5 million people that have moved to AZ in the last 10 years. The same issue is happening to the VA. We are getting very sick returning Veterans. Not to mention the enrolements in medical schools are at there lowest and continue to drop and the indivules in meical schools are not choosing Primary Care but going into higher paying fields. The big question who is left to care for these people.

    • Karen says:

      I am offended by the comment that skill level is too varied among NP’s to allow independent practice. Would the same not be true of physicians? What makes a person think that they are uniformly superior? Our education and board certification practice is standardized, just as it is for a physician. Based on the above mentioned logic and given my exposure to some rather poor physician practices, I would say the same for MD’s.

    • Cathy Mann says:

      Unfortunately quality of care cannot be determined by passing certification or board exams. Quality of care is determined by the provider. Expertise cannot be purchased but is earned over time. APRNs are taught to base their practice on the best evidence and to use the guidelines provided by this evidence to determine practice. The question is how to increase access to healthcare for our population? Removing barriers to APRNs independent practice does not mean they will be taking the place of physicians or specialty trained providers.

  2. Eve L Broughton says:

    All APRNS are educated to the same level regardless of where they attend school or what state they end up practicing in.

    Why would they have different levels of practice if all of there education is standarized?

    • Mark Soucy says:

      The Consensus Model of Regulation of Advanced Practice Nurses and subsequently, the LACE implementation model have paved the way for uniform regulation and practice of APRNs. We are closer than ever to Compact licensure of APRNs such as what is in place in many states for RN licensure. Calls from major leaders and organizations in the past few years emphasize the need for Advanced Practice Registered Nurses to practice to the full scope of their education and training. As the DoD does, the Veteran’s Administration is wise to enact a standardized scope of practice federally, which is their right. Such an action will benefit patient’s through comprehensive and true inter-professional care.

  3. Patricia says:

    advanced practice nurses are independent licensed nursing trained providers but not independent licensed medicine trained providers – medicine trained (physicians) professionals should ALWAYS be the gatekeeper of the public’s healthcare system

    • Karen DNP,ACNP-BC says:

      I’m sorry, that comment says without question you are not an NP or familiar with the degree of expertise with which we practice. Research which is more reliable than “I think”, has proven consistently here and in the UK that NP’s not only do it better because we are able to provide the same service and do it for less, but also have patient satisfaction that is equal or superior to physicians. The ONLY reason there is for this debate is MD’s are scared. They opened the door for NP’s by not wanting to do the dirty work and we came in like gangbusters doing Primary and specialty care. Gatekeepers to our heatlth care system. I don’t think so. In fact, I expect as soon as we get the recognition we deserve there will be a Surgeon General who is a nurse!

      • Kristen says:

        As an APNP in NY my training was from the first week as an RN, not in my 3 or 4 yr of academia that waited until masters level education. I also had to take a. Separate pharmacy test to qualify for my license. I had 8 yrs of training in medicine not including my 4 yrs of education and research and lab time for my doctorate in Sports Medicine. Many of my peers are clinically trained DNPs, which for many is 10-12 yrs of education in medicine. No I am not an MD but I sure did my time to be called a medical professional qualified to diagnose and treat many health issues. Oh yes I earned the right to be called doctor by patients, whether MDs appreciate it or not.

    • MaryAnne Murray says:

      “Medicine trained (physicians) professionals should ALWAYS be the gatekeeper of the public’s healthcare system”–WHY? You think they’ve done such a great job? We have a very poor quality (low longevity, high infant mortality, highest cost per capita) SICK CARE SYSTEM. In the 1940s the AMA put megabucks into lobbying against Truman’s plan for a single-payer healthcare system. The MDs tried to shut out the Osteopaths, Chiropractors, and Naturopaths, all of whom have a lot to offer to the health and wellbeing of our nation. As long as MDs get paid to do stuff (e.g., surgery and other procedures) rather than promote an ideal of biopsychosociospiritual wellbeing, they should not be the gatekeepers of our healthcare system. Perhaps if they were not in cahoots with the gouging pharmaceutical companies and insurance companies I might feel/think differently! Rather, our health system should be based on health promotion, with guidelines which focus on healthful nutrition and lifestyle (not just prescribe this drug for this risk factor).

    • Dr Kimberly Shmina, DNP, RN, FNP-BC says:

      I respectfully disagree with you assertion that Physicians should be the gatekeepers…What every gave you the idea that a medical doctor should be a Healthcare gatekeeper? Physicians have very little training in prevention, nutrition, research,rehab, breastfeeding, and a dozens of other areas which are absolutely essential in HEALTHCARE. In fact, Healthcare is much more than simply disease management. Just look at the stats regarding mortality and morbidity in the US. They are terrible, and that is with “Physicians” in charge. It is time for a change from “see one, do one, teach one,” to healthcare as a holistic continuium with health care partners, not gatekeepers! Also, you have no idea how I was trained, my levels of expertise, my areas of research, and my experience. You comment is insulting.

  4. marty nunley says:

    it is my understanding that nurses in military are covered by state but also by federal which can supercede state on federal property;
    i am a va np, licenced in one state working in another, so long as i am working for federal gov, i see nothing wrong with this, and so not see how it is different from the military system which seems to work well, and it certainly helps me when it comes time to renew not to have to renew in the states i have been licenced in.

  5. Ada says:

    It is now 52 yrs post inception of the Advanced Nurse Practice role(Nurse Practitioner). Practice should be standardized supporting our independent practice just like physicians. In addition, APN’s should be properly financially compensated for providing the level of care that is equivalent to , and as the research proves, is often superior to that provided by physician counterparts. It is very interesting that in addition to their base salaries, VA physicians receive “incentive bonuses or whatever these are called” on a biannual basis as we have been informed. This is discriminatory, as we are providing the same care as physician counterparts are providing. It would be in the best interest of all for the VA to acknowledge APN’s for their educational & experiential attributes and move forward to try to “catch up” to the private sector as it relates to advanced nursing practice. Since physicians are very nicely compensated financially in addition to their base salaries, so should APN’s. Again, historically the VA has been overtly discriminatory against APN’s in terms of financial renumeration and our independence in practice,. Clearly the VA has not given a second thought to assignments-in this respect there is no differenence between the two provider roles with APN’s assigned with significant work loads and being the designated provider for very complex patients. The ambivalence presented by the VA in this regard is quite sad.

  6. Angelique says:

    Changing this policy will allow Nurse Practitioners to provide comprehensive care to our Veterans in a way that is not encumbered by the current policies. Multiple conflicting regulations are confusing, and constrain the delivery of much needed care to our nation’s Veterans.

  7. Kathrene Berger says:

    NPs understand that they are generalist and know when to refer and or seek collaboration from a colleague. Current systems of subjugation are unnecessary and slow or impede access to care. This is true of many states that limit prescriptive access as well. The need is too great to continue territorial marking by physicians who don’t want the positions NPs largely fill anyway!

  8. CR Venneman II MD says:

    Advance practice nurses no matter how you try to label
    them do not have the training, expertise, or forsight
    equivalent to board certified physicians. There absolutely will be substandard patient care for the
    veterans when compared to private practice within this
    proposed setting and I believe a significant number
    of physician providers will leave the VA system.
    Myself included.

    • Randall Sexton, APRN says:

      I’m a Psychiatric Nurse Practitioner working with active duty Soldiers at an Army post. I’ve worked independently since I graduated from school. I’m currently not in an independent practice state but all the physicians I work never question my work, in spite of me being the only prescriber for a walk-in clinic where I see everyone’s patients (which is good as I see how many physicians practice). Soldiers routinely request to switch to my services. Anytime I want to I can certainly walk down the hall and consult with one of the physicians but I get no more supervision than anyone else in our group from our managing physician. By the way, everyone of us ONLY admit a patient to the VA if there is no other choice. It take me a few minutes to admit to a private facility and hours to the VA, if we can get someone to not give us the run around. They are so inept it’s pathetic. We need quite a few people to leave the VA system. I hope I’ll always have a job working with active duty Soldiers!

      • Roy H. Smith, DNP, FNP-BC says:

        Well the patients I see already verbalize that they do not get quality care at the VA…so perhaps allowing NP’s independant practice would make a difference. And Dr Venneman your opinion about the quality of care provided by NP’s is simply not backed by the research.

        • Randall Sexton, APRN says:

          I did a hospital return this morning on one of our Soldiers who spent 5 days in a VA. Came back with no paperwork, body odor, and told me they didn’t have Strattera and his current dose of Prozac so he was afraid to take anything. He called the place “loopy.”

    • Troy Pierky, NP says:

      Dr Venneman,
      Where sir do you get your information? I encourage to review the literature. Fifty years of peer reviewed data validate over and over again the superior quality and safety of care provided by Nurse Practitioners. In fact, NPs score higher than MDs on more than one of the metrics measured in these studies -especially patient satisfaction. In legal interpretations from attorney Buppert,JD (2013)he determined NPs liability is increased and they are more likely to be involved in litigation because of the requisite affiliation with MDs. In the future please take a moment to review empirical literature before you make-up anecdotal stories about the NP profession. The old were gonna leave threat has lost its luster. thank you

    • Marcy Buzanowicz DNP says:

      “Advance practice nurses no matter how you try to label them do not have the training, expertise, or forsight equivalent to board certified physicians. There absolutely will be substandard patient care for the veterans when compared to private practice within this proposed setting”. I find these comments interesting and unfounded.

      As a doctoral prepared advanced practice nurse in the VA system, I have found no research to substantiate these statements. If you would please back up your statements with credible research perhaps more readers would respect your comments. Historically it was noted that substandard care was delivered by both professions, however both are required to deliver high quality care and are mandated to follow the same VA standards of care.

  9. Stephanie averette says:

    I am a female vet and a daughter of a veteran who lives in a rural area and depends on the
    VA outpatient clinic in orangeburg SC for care. for several months he has not been able to get care at that facility because there is not a physician working in that clinic presently. I would love for advanced practice nurses to have the opportunity to give independent care to the vets in rural areas.

  10. R Harter says:

    Our veternas deserve to receive care from doctors, NOT lesser skilled providers.

    • Roy H. Smith, DNP, FNP-BC says:

      Veterans can choose a physician or an NP…but at least allow the NP’s to be independant so that the people who choose the NP can get unencumbered care. R. Harter we don’t mind if you would prefer to wait for months to get an appointment with a physician instead of getting the same or better care sooner from an NP -but don’t make it harder for everyone else who values the quality and level of care given by Nurse Practitioners.

    • Elizabeth Crooks, DNP, RN, CNE says:

      Twenty years of research using randomized clinical trials that measure patient outcomes based on care provided by physicians vs. nurse practioners demonstrates that the quality of care is eqivalent. Advanced practice nurses are not lesser skilled, they are equivalently educated and skilled and the evidence is there to back this up.

    • Sherri Mason, MSN, APRN, FNP-C says:

      Our veterans, my husband included, deserve to have unencumbered access to quality care from a provider appropriate to their presenting complaint. The VA system will be a more effective system when NPs are allowed to practice to the full extent of their preparation. Multiple trials have indicated higher patient satisfaction with NPs and at least equivalent quality of care to that of MD counterparts. NPs do not want to replace MDs, they want to provide quality care for patients and work as a part of a healthcare team.

    • Marcy Buzanowicz DNP says:

      R Harter,
      Please define ‘lesser providers’. I believe that you are not well informed on the role of an advanced practice nurse.

  11. linda baker acnp says:

    The VA should not standardize practice for APNs across all facilities becomes evident when one transfers from one VA to another, especially from one VISN to another. All VAs are not the same. All VA management is not the same. All VA physicians’ needs and work relationship with APNs are not the same. I fear that the standardization may limit APNs to the lowest common denominator. APNs should be allowed to practice to the full extent of their training and education.

  12. How can a nurse that gets an advanced degree on a computer even be considered to practice independently?
    This is totally absurd. Years of hands on training i.e. medical school, internship, residency,and fellowship training qualify one to practice independently. If they want to be doctors and practice independently, then they need to go to medical school.

    • J Santeth says:

      Nurses don’t get advanced degrees on computers. We do have years of training, both hands on and didactic.

      The poll should ask “should APRNs be allowed to practice to the full extent of their education throughout the VA?” I think it should only standardize practice if it increases our scope.

    • T W says:

      As the other responder mentioned, there are online NP and MD programs, however the clinical portions and testing portions are in proctored environments, with clinicals supervised by a skilled clinician. Therefore, unskilled NP’s should hopefully not fall through the cracks. In addition, a final comprehensive national board exam must be taken prior to being allowed the privilege to practice. However, as with any providers when switching to different areas of skill, the skill-set may vary widely. Therefore, a family nurse practitioner working in an orthopedic environment may or may not be the most competent provider. It really depends.

      I sincerely believe veterans deserve the best care from any providers who are compassionate and skilled to provide individualized care for them. I have practiced in the VA system and have noticed that the NP’s have spent more time with patients, provided timely referrals and have a vested interest with a nursing background in ensuring that each veteran’s voice is heard.

    • RN says:

      Wow! Then don’t go to a nurse practitioner you have a choice. When you want a provider to listen intensely, spend the time with you while not holding the door knob to rush you along, maybe then you will change your mind. No matter how the nurse practitioner earned their degree, they had to do clinical hours and prove that they were skilled and knowledgable to provide excellent care to their patients. Everyone has a choice and some may choose to stay with their physician but in times of need they may reconsider. Many nurse practitioners have spent many years working as a nurse in various settings. This time, energy, experience and expertise should not be discredited.

  13. Diane Styk says:

    I work in the VA and standardized care is the only way to go…having APRN w/ different scopes based on state narrow mindedness does not aid in Veteran care. this is the VA..we all need to work together.

  14. John says:

    I think more evidence is needed before a forthcoming sweep of legislation is to be used. Pilot this idea first to see which problems arise so this would be a better, more informed decision.

    • David says:

      John,

      There have been numerous research studies published that demonstrate the safety of advanced practice nurses working independently. This decision is being considered because of these studies, as well as, the past implementation of this standard in the military and Indian Health Service.

    • Marilyn says:

      There is an extensive data base on the positive outcomes achieved by APRNs. Cumbersome barriers perpetuate the status quo which delays access to veterans of needed health care. APRNs are wanting to practice nursing not be junior docs

    • Roger says:

      Dear John, you need to learn about EBP. As and FNP-BC I can tell you we do a good job caring for our patients. However, there are, at least I can think of, 30 studies by major University on the quality of care APRNs (NPs) provid. You should try reading some of them.

  15. Randy Beckett NP-C says:

    The VA has done groundbreaking work in EHR and integrated care teams. Changing its policies to allow APRNs to practice to the full extent of their training is a similar forward thinking decision.

    • Roger says:

      I agree with you. The VA leads in many healthcare policies and this should be one too. Next, the states should look and follow as well. Holding NPs back only hurts the public.

  16. PATRICIA ANNE BROWN says:

    WE HAVE STUDIED, WORK VERY HARD.WE ARE ALREADY DOING THE WORK, THE SAME AS THE MDS. AT TIMES MORE.

  17. Sally Mann says:

    I think np are qualified to practice under there own liscense

  18. Tony says:

    Because there is still wide variability in the scope of training of Advanced Practice Nurses, it does not make sense to standardize their privileges across the whole system.

    • Karen Kelly says:

      All NPs are educationally prepared to the same standards across the country because of standards set by accrediting bodies of schools/colleges of nursing and the standards set by certifying organizations. It seems that MDs had no trouble with NPs in the 1960s when the first NPs were prepared primarily in certificate programs affiliated with medical schools. But, when nursing education took over the programs and mandated graduate education, MDs began to worry about the practice of NPs.

  19. Dr. Stephanie Burgess, PhD, APRN, BC says:

    Robust literaure and evidence support that APRNs are very safe providers and deliver quality heatlhcare that increases access and is cost effective. APRNS should be authorized to practice as independent providers. Physician groups are opposed to any group expanding their practice. But we need to be more concerned about access, cost, and quality.

    • Katheryn says:

      Thank you–it’s heartening to see a physician in support of standardization/independent practice.
      the NP’s (including myself) in OR are independent practitioners. VA providers (NP’s, docs, PA’s) are working their tails off and need to be as unencumbered as possible. ANY provider needs to know their limits and seek consultation/referral as indicated as a part of providing good patient care. Comments like “getting their degrees on a computer’ are misinformed, marginalizing, and non-collegial. We all might want to consider supporting one another and remember our common goal of providing excellant care to our vets.

      • David Hosack says:

        DR Burgess is a PhD, not a medical Docter and her’s is the only comment that eludes to research and documentation to support her position.

  20. Mark Cannon says:

    The current board certification requirement for APRN/NP is one time pass without requirement for recertification. Medicine is a profession that constantly changes. A lot of critical skills and knowledge must be maintained and verified to ensure proper and safe care of VA customers. Without this verification, the VA may be placing the veteran at risk of substandard care AND itself at risk for legal action should the unfortunate mistake occur because of outdated/obsolete care practices. CME requirement does not verify knowledge and understanding of current practice. The VA should do whatever it can to require that ALL the providers have verifiable current practice knowledge through recertification.

    • David says:

      Mr Cannon,

      I cannot speak of the requirements of the NP field regarding recertification. Although, I can regarding recertification of CRNA’s. CRNA’s currently recertify every two years with a required CEU requirement during this period to maintain knowledge. Our career field has also initiated a new recertification process which will require increased CEU requirements AND also a computer based recertification exam to keep us current in our practice knowledge. I submit these requirements are more stringent than an anesthesiologist must go through. I see the care CRNA’s provide everyday. The care the vets receive is safe and not substandard, as you suggest, and doesn’t place the vet at an increased risk.

    • Dr. Ruth Milstein, DNP, PMHNP- BC, LMHC says:

      Re certification iS required!. Know your facts before commenting. Be informed before you knock something. We have CEU/CME requirements also. I am the Chairman of the content expert panel for the ANCC (in my specialty) which is the National credentialing agency. All NP’s must pass a national exam to become certified and be re certified every 5 years (or sooner depending on specialty). We don’t want to be doctors – if we did we would have gone to medical school. We are not a threat to MD’s but many are so insecure that this is how they feel. There are not enough doctors for all veterans to get care. Kudos to the VA for their desire to provide care for all veterans.

  21. Heather Clarke says:

    Standardization of designation as independent practitioners is consistent with the VA’s policy to accept any current state license as a requirement for practice in one of their facilities. The ruling could also pave the way for similar federal statues across state lines.

  22. Mary Lou Guerrina APRN BC says:

    I am in full support of standardize practice throughout the VA system and lessening of restrictions nation wide inorder to support the Affordable Care Act. APRNs are the solution to the primary care provider shortage.

  23. Mona Child says:

    Mr. Canon is misinformed as are several others that have posted. ARNP’s have Masters or Doctoral degrees. They are initially certified nationally by examination – as are physicians. Recertification is required every 2 or 3 years which requires ongoing continuing education. Nurse practioners have varying scopes of practice and concentration areas. The best NP’s work collaboratively with MD’s, RN’s, MSW’s (Social Workers) and the rest of the medical team. All NP’s are taught – as are MD’s to consult or refer when a medical or psychiatric condition is outside their areas of expertise.

  24. Kate Wheeler Ph.D., APRN-BC says:

    Continuing the patriarchal system of physicians being responsible for the care that NPs give does serve our veterans or military, NPs, or MDs well. It adds a layer of complexity to the delivery of health care that is unnecessary since all studies point to the safe and quality care given by NPs. See the 2010 IOM Report on The Future of Nursing. Why would physicians want to be liable for someone elses’ practice? Perhaps it is more about money and power than the reality of the care given.

  25. M. Bain says:

    My Father received excellent care from VA MD, NP, and APNA nurses alike. The MD’s provided a more complex medical care in the acute setting – and the NP’s and APNAs provided a very high quality specific care in all settings. Were it not for the APNA wound care nurses and urology nurses we would have waited ridiculous amounts of time for care. In addition – the quality of care was higher than he received at local community hospitals.

    In terms of the patient – all providers lic.’s should be standardized. That makes sense in this healthcare world.

    In terms of physicians refusing to work with lic. and certified providers NP/APNA or otherwise …those that can not work effectively in a multidisciplinary team should leave and make room for those that can. The latter is more an issue of ego than patient care.

  26. Susan Bissette ANP-C says:

    I worked at the VA in Primary Care for many years. I applaud this effort to standardize the NP practice and to make them (officially) independent practitioners. In truth, working at the VA, the NPs were already independent practitioners. Any time I had a question, I would ask the closest MD, NP or PA. There is always someone around to chime in. Research has shown that the NP practice is extremely safe. Most patients value the relationship with an NP and the type of practice they offer, which is often much more comprehensive than the MDs, perhaps because we are well-trained to be good communicators. In the coming years the nurse practitioner will be the heavily relied upon if the ACA goes forward as written.

  27. Rick Pessagno, DNP, APN-C says:

    The evidence from several studies clearly cite that Advanced Practice Nurses (APN’s) provide safe, quality patient care (Newhouse, et al, 2008; Ohman-Stricland, et al, 2008; Mundigner, et al, 2000; Spitzer, et al, 1974). This evidence has been published in well-respected journals including Annuals of Family Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and Nursing Economics. Much of the push back from physicians and physician groups is based on personal bias and not based on science or evidence. If there is published evidence that cites APN’s are not safe or that they provide unsafe care, where is that evidence published? The lack of such evidence further suggests that the physician push back is not based on science. It is true that the education and training of physicians and APN’s is different, there is no dispute there. Yet APN’s are well educated (many are doctorally prepared), licensed and board certified in their specialty. Boards of Nursing across this country are legislated to assure all licensed nurses are educated, licensed and competent in order to protect the public, and those Boards of Nurses have been doing that work. The truth is that APN’s are educated and trained to competently and safely provide some of the same services that physicians provide with positive, quality outcomes. This doesn’t negate the need for physicians in our healthcare system but it does suggest that there might be better models of care that can be developed and utilized to meet the healthcare needs of the more the 300 million Americans in this country. To suggest that APNs are unsafe, provide poor quality care, or would want to place patient’s at risk is unfounded and ludicrous. The truth is that the model utilizing the full scope of practice for APN’s is already working and effective in 16 states. Patients in these states are no less safe or at risk than individuals in other states in the US. Decisions to create change relative to full scope of practice of the APN needs to based on evidence not fear, personal bias, turf protection, or supposition.

  28. Hello,

    I am an independent ARNP, I practiced one year with a WWII veteran family practice MD, learned a lot. I often was told, do not refer to specialists, keep that money in house. I do C & P PE one am a week, my husband is a retired Vietnam Veteran, and I love giving back to my VETS! Thank you for my lifestyle!!!

    I eventually went to work with 3 other ARNP in an independent LLC practice. We each have our own practice, and run overhead thru a LLC. I have been practicing for 13 years. My asociate, developed and started Gonzaga University’s ARNP program. Spokane WA

    WE perform mid level family practice, have a very busy practice, as do we all. First year NP students find our practice too complicated, as mostly it is internal medicine. So we only take last semester students. Several patients, due to insurance have gone to Rockwood & etc, here in Spokane, WA, to come back to me as soon as possible. They receive 6 min a visit, often w/a timer, and receive minimun 15 min w/me.

    I see a lot of Medicaid/Medicare, as other MD’s will not take, as they pay too little. I went into this business to help, and I made more money working in open heart surgery as an RN, but I LOVE what I do. I know my limits, I refer when in doubt, and or make calls. I do not allow patients to call me DR., and our PhD ARNP – well, his patients know the difference. PhD vs MD

    I legally am allowed to diagnosis, treat, prescribe, sign death certificates, digoxin etc, but due to MD fraud in the past….can you believe this, I cannot sign for diabetic shoes, but then nor can the renal specialists, as I manage the blood sugar. CRAZY medicare system…..part A and B

    I feel mid levels have a hugh place in the medical profession.

    Sincerely,

    R. Lee ARNP

    • Casey Fowler, ARNP says:

      Rhonna Lee,

      If we want more freedom to practice, we HAVE TO STOP CALLING OUTSELVED MID LEVELS! That suggests that physicians are higher level providers than them. We can do more than a PA, so why be classified with them?

      Casey

      • Phil Kucas, PA-C, MPAS says:

        I agree. The term “Midlevel” has long annoyed me. It implies that NPs and PAs are “somewhere between” an RN and MD/DO
        If I were an RN, I would be insulted. As a PA, I resent the implication that PA and/or NP care is somehow inferior to physician care. The term “extender” is equally insufficient. How about Nurse Practitioner and Physician Assistant?

        As to the last comment, I’m not sure what it means. I’ve worked with NPs and other PAs in multiple settings in the past 30+ years. Clinical
        responsibilities and privileges were virtually identical. This includes my current VA practice setting, where I work with a physician and 2 skilled NPs. We all consult each other from time to time.
        As to the “concerns” for patient safety, studies of PA/NP practice over decades have demonstrated equal or better than physician care. In fact, at least one author came to the conclusion that one of the best ways for physicians in primary care to
        Decrease liability was to hire an NP or PA.

        By the way folks (MD,NP,PA,DO), the last time I checked, there were Way more than enough patients in need of primary care to go around.

  29. I am in full support of standardize practice throughout the VA system and lessening of restrictions nation wide inorder to support the Affordable Care Act. APRNs are the solution to the primary care provider shortage.

  30. Lucille Joel, APN, EdD says:

    Multidisciplinary teams are vital to cost-efficiency, quality and access. This does not equate with physician led teams. The team leader should be contextually determined according to the presenting case. APRNs represent a valuable attribute and should practice to the full extent of their preparation, and the VA is a good place to demonstrate this ability. APRNs are quick to refer-out those cases beyond their scope; check the liability statistics. They are also predisposed to support self-care and self-management with their clients, which may be out only hope to control health care costs.

  31. Pam Hamilton, MPAS, PA-C says:

    I do not think that by artificially elevating credentials to “Doctor” that anything is gained in the provision of quality patient care. I feel the title is misleading in patient care, if one is not MD or DO. I am happy to see an NP in my pcp’s practice, but an NP is not a “dcotor” to me. The same case can be made for pharmacists, physical therapists, and now NPs. Education is being priced out of reach of many, student debt is crippling, and where is ANY evidence that patient care quality is improved.

    • Marcy Buzanowicz DNP says:

      Ms. Hamililton,
      The title doctor is not owned by the profession of medicine or physicians. It is a level of education. Anyone who has strived to achived that level of doctorate deserves the title “doctor”.

  32. Sharon Holley, DNP, CNM says:

    With all due respect to one physician’s comments in this comment section I would like to reply to the statement made, “Advance practice nurses no matter how you try to label them do not have the training, expertise, or forsight
    equivalent to board certified physicians. There absolutely will be substandard patient care…” I find this statement very ironic. In my own institution, a large teaching hospital in the South, our APNs have made amazing impact on the outcomes and quality of care at our institution. Our physician colleagues recognize this and are respectful of the role of the APN within the healthcare system. This statement is a sad reflection of lack of education on what APNs contribute with their care. I can say unequivocally in the very busy department I work in it has been the APNs who have brought the new innovative ideas to the table that produced the quality improvements and better patient outcomes over the last few years. I would expect the same at the VA if APNs are uniformly able to practice state to state within the system. The military healthcare system is a prime example of how this can be accomplished with standardizing nursing care. The VA would do well to do the same for APNs. Training for APNs is not inferior to medical training, rather APN training though based on the nursing model offers a more holistic view of the patient. The physician adds the expertise when there are needs that cannot be met by an APN. The fact of the matter is that both physicians and APNs can work together and offer the best care for a patient.

  33. Mary Bennett PhD APRN says:

    The VA and military have been getting around state level restrictions for years. If you work as a nurse, MD or APRN for the military or VA, you don’t have to have a license in that state, as long as you have a license in at least one STate in the US.. I wish this were the case all across the US. It would make it easier for people to help out in an emergency if the emergency is across a state line.. And allowing APRNs to practice to the full extent of their educational preparation is the recomendation of the Institiue of Medicine, the US state governors group and other organizations based on the currently available evidence of their effectiveness.

  34. Joyce Simon says:

    I worked for 15 years as a nurse practitioner in a V A hospital. There is no doubt in my mind or in the minds of the veterans that they had received excellent care from this provider. The time effort and my overall experience was equal to the physician staff. I left the VA because the new chief of service targeted me as an NP, and made my life miserable. This physician, was a poor clinician a poor researcher, and most of all the worst manager I had ever seen. Nurse Practitioners, have experience, compassion, that make them excellent practitioners. Physicians often have a very different view and approach to the patient that really lacks compassion.
    The research clearly shows overall patients feel they have received at
    least as good care from an N P as from a physician and very often feel they have received better care.

  35. VAL BOATMAN says:

    AS A VIETNAM MEDICAL VERTERAN NURSE PRACTITIONERS HAS ALWAYS BEEN THE WAY TO GO! HERE IN TAOS, NEW MEXICO OUR VA CLINIC OPENED TWO YEARS AGO WITH A ANGEL NURSE PRACTITIONER AT THE HELM!! HER NAME WAS RONA, SHE HELPED EVERYONE!!! SIX MONTHS LATER SHE WAS REPLACED WITH A DOCTOR, HE HELPED ALMOST NO ONE!!!! Six MONTHS LATER HE WAS GONE, AND NOW WE (TAOS) HAVE A WONDERFUL TEMPORERY NURSE PRACTITIONER, WE (TAOS) HOPE & PRAY SHE STAYS FOREVER!!!!!WE BEGG OF YOU VA!!!!!!

    THANK YOU FOR THE RANT,

    VAL M. BOATMAN
    RE-TIRED MILITARY

  36. Liz says:

    I have read and re-read many of the above comments and sense alot of resentment towards Dr’s. No one is disputing the fact that NP’s provide quality care, but to want to practice independently is only inviting trouble. Why can’t you be happy with working WITH the doctors instead of AGAINST them. Experience is one thing, but PA’s, NP’s and other mid level providers do not have the education of a physician. If we keep making more advanced degrees ie Pharm D, Doctorate in Nurse Practitioner etc., pretty soon everyone will be calling themself doctor.

    • Ginger APRN ANP-BC says:

      The VA Handbook changes are really not about trying to make a NP equivalent to a physician. NP’s within the VA have had independent prescriptive authority for many year (with the exception of narcotic agents). However, within the VA the challenge becomes that there is not a requirement to maintain a licensure of practice within the state of practice only a license to practice within at least one state. So consider this challenge you work at a VA within a state which allows autonomous practice but a nurse practitioner is hired from another state which has stricter regulations on practice. Both NP’s underwent a training which was at an accredited school with curriculum established by a national accrediting body (required elements are the same), both of you took a national board accreditation exam which was identical for all NP’s throughout the nation (regardless of state of education or anticipated state of licensure). But because you are licensed within a state with less autonomy you cannot provide similar services as the other nurse practitioner who works in the same clinic as you. Eventually those VA facilities will decide that perhaps all of their staff should seek licensure in a state with autonomous practice, or perhaps they recruit NP’s from other states due to their state licensure laws. The question about NP practice within the VA, at least in my view, is less about allowing an NP to practice to the same level as an MD (because quite honestly all of the NPs who have made comment here likely recognize their limitation and need for consultation with a more knowledgeable provider for those complex cases) but more about allowing for consistent practice across VA facilities for NP’s. The call for movement for doctorate level of entry for practice is not coming from the disciplines who are working now (Physical Therapy, PA’s, NP’s, Pharmacists) but more from the professional communities who are pushing to make this entry level for practice. While I do believe it may be beneficial in regards to safety, not really sold that it is a necessity, it unnecessarily increases educational costs, and decrease time to prepare new members to the workforce. But it is not because NP’s want to be ‘doctors’. I believe all of us (NPs) realize we are not equivalent and do not intend to be equivalent to a Physician. But I do believe that we are able to manage a panel of patients. And a good majority of those patients won’t require further consultation with a Physician. And regardless of the question as to whether the NP has the ability for autonomous practice, I believe they will continue to refer patients who have the complex needs to a Physician. I have not been able to understand the perception of conflict between the NP and MD role. The NP’s will still need the Physicians and understand that we cannot replace them. I find that the Physicians in my area who have multiple NP’s who collaborate with them, and increase their bottom line, are very much accepted. Unfortunately, there is not the same financial incentive within the VA for the Physicians to accept the NP’s.

      I frequently look at USA JOBS, and there are ALWAYS multiple physician openings posted which need to be filled (to ensure our Veterans receive optimum health care). Without the NPs within the VA how are we going to care for those who served our country and fought for the freedoms we enjoy each day? And just think about the change and potential for improved disease management which is possible if usage of the NP role frees up some of the Physicians currently employed to help to explore improved care delivery measures or to provide focused care to those with complex illnesses in a way which is unlikely to be realized utilizing the current for profit care delivery model utilized in the private sector which has went unchanged in its basic premise for some time. Perhaps NP utilization within the VA will allow for an opportunity to move from individual patient disease management to population health promotion that may bring redesigned care delivery methods that fundamentally changes the way primary health care is delivered. Perhaps this is really very much like the combine which took place of the plow. Because if the forecast is right with implementation of a national health insurance model increasing demand for healthcare with little potential to increase supply of providers the person who looses is the patient. And when the office visit goes from 15 to 10 minutes and the provider begins to be more of a check out person no longer able to really utilize the knowledge and skills they posses.

  37. Troy Pierky, NP says:

    I encourage you to review the literature. Fifty years of peer reviewed data validate over and over again the superior quality and safety of care provided by Nurse Practitioners. In fact, NPs score higher than MDs on more than one of the metrics measured in these studies -especially patient satisfaction. In legal interpretations from attorney Buppert,JD (2013)he determined NPs liability is increased and they are more likely to be involved in litigation because of the requisite affiliation with MDs. In the future please take a moment to review empirical literature before you make-up anecdotal stories about the NP profession. thank you

  38. Roger says:

    I beleive that nursing needs to be one standard, that is why we have the NCLEX. Now as an DNP-C and and FNP-BC I have worked in a state where all NPs are LIP and we provider care at or above the standards for our communities. I beleive the VA should be a leader in this fight to provider care for all Americans. If APRNs are able to act as LIPs then more people would be able to get healthcare. The people worried about this should look at the EVC studies that have proven this time and time again. It is a income issue for most MD/DOs or the fear that we will take income away from them. Lets get past that and thank about the people we serve.

  39. 663 says:

    I contend that VA nurse practioners and physicians’ assistants should share the same nominal physician supervision requirements. These standards should be uniform across the VA.
    Our VA physician and surgeon colleagues are also all nominally supervised by their respective service and clinic chiefs and medical staff supervisory boards. It’s really not that onerous a proposition.
    I also contend that all current & future VA mid-level provider vacancy positions should be made eligible to be filled by either a physicians’ assistant or nurse practioner and that we should share identical pay scales.
    Currently there is a strong VA bias towards hiring nurse practioners instead of physician assistants. This should end.
    Also, VA nurse practioners are now paid more than their VA physician assistant peers performing identical or even more responsible patient care duties.
    This should also end.
    Just because VA nurse practioners outnumber VA physicians’ assistants almost three to one now and have an Assistant Secretary level advocate serving as the Assistant Secretary for VA Nursing Affairs doesn’t mean that physicians’ assistants in the VA shouldn’t have the same employment opportunities and receive equal pay for equal work.
    Fair is fair.

  40. Kim, RN says:

    In light of the current scandal surrounding the delay of care at many Veteran’s Affairs (VA) hospitals, it seems timely that the Veteran’s Health Administration (VHA) revised their nursing handbook to recognize advanced practice registered nurses (APRNs) as licensed independent practitioners (LIPs) in all VA facilities. As patient outcomes are increasingly becoming an indicator of quality care, the VA’s mismanagement of care, and poor patient outcomes reflect a system that has been broken for quite some time. Recent news reports discuss not only insufficient staffing that produces lengthy wait times, but also unsanitary conditions, misconduct at leadership levels, and low patient satisfaction. It will not be a quick and easy fix, but there is a fix in which APN’s must play an integral role.
    First and foremost, utilizing APN’s within their full scope of practice increases opportunities and decreases wait times for patients seeking healthcare services. The physician’s patient load is decreased allowing more time for individualized care rather than herding patients through an assembly line. As researchers, APN’s discover and disseminate evidence-based data which promotes optimal patient outcomes. APN administrators integrate evidence-based practice into the organization’s culture to inspire quality care and better patient outcomes.
    The VA health system will continue to be challenged as veterans return home from Iraq and Afghanistan. APN’s consistently offer attentive, personalized care to their patients in clinical care, health education and promotion, disease prevention, and counseling. This explains why Budzi, Lurie, Singh, & Hooker (2010) found that veterans preferred to see nurse practitioners in the primary care clinic compared to the physician or physician assistant. With the revision of APRN practice, the VHA has taken a positive first step towards cost effective, quality health care for our veterans. With improved access to care, patient satisfaction increases which results in better compliance and optimal health outcomes.
    Reference:
    Budzi, D., Lurie, S., Singh, K., & Hooker, R. (2010). Veterans’ perceptions of care by nurse practitioners, physician assistants, and physicians: A comparison from satisfaction surveys. Journal of the American Academy of Nurse Practitioners, 22(3), 170-176. doi:10.1111/j.1745-7599.2010.00489.x

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