Exclusion of Fourth, CRNAs, Fuels Controversy

By Brenda L. Mooney

Last spring, about 500 nurse anesthetists from around the country converged on the U.S. Capitol to support the plan proposed by the VA to expand veterans’ access to healthcare by allowing broader scope of practice for advanced practice registered nurses, including certified nurse anesthetists.
American Association of Nurse Anesthetist photo by John Wheeler Commercial Photography

WASHINGTON—The VA has granted full practice authority to three roles of advanced practice registered nurses (APRN) to practice to the full extent of their education, training and certification, regardless of state restrictions.


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The change, which affects certified nurse practitioners, clinical nurse specialists and certified nurse midwives who are acting within the scope of their VA employment, was expected after an announcement earlier this year and months of Federal Register comment periods, attracting more than 100,000 responses.

What was less expected—and has produced substantial controversy—

is the VA’s decision to exclude Certified Registered Nurse Anesthetists (CRNA) from the expansion of practice.

“CRNAs provide an invaluable service to our veterans,” said Under Secretary for Health David J. Shulkin, MD. “Though CRNAs will not be included in VA’s full practice authority under this final rule, we are requesting comments on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rule-making. In the meantime, we owe it to veterans to increase access to care in areas where we know we have immediate and broad access challenges.”

The response was swift and sharp from the profession. “This is an example of the kind of potentially dangerous decision-making within the VA that has led to all-too-frequent media reports of terrible neglect and bad outcomes in VHA facilities,” emphasized Cheryl Nimmo, DNP, MSHSA, CRNA, president of the 50,000-member American Association of Nurse Anesthetists (AANA).

“Just imagine how many more veterans could be cared for if start times for surgical and other types of cases requiring anesthesia were no longer delayed unnecessarily while waiting for supervising anesthesiologists to become available,” Nimmo added.

The decision was applauded, however, by the American Society of Anesthesiologists (ASA), which had been in bitter opposition to expansion of practice for CRNAs.

“This was the right decision for our nation’s veterans and for safe patient care,” said Jeffrey Plagenhoef, MD, president of the physicians group. “We’re thrilled with the VA’s decision to remove anesthesia from the new Advanced Practice Registered Nurses rule. We commend VA’s leadership for their recognition that the operating room is a unique care setting and that surgery and anesthesia are inherently dangerous, requiring physician leadership. This is true for anyone, but especially for our nation’s veterans, given many of them have multiple medical conditions that put them at greater risk for complications during and after surgery and anesthesia.”

The VA explained that, while localized issues with providing anesthesia care exist, the healthcare system doesn’t have “immediate and broad access challenges in the area of anesthesia care” to require broader practice authority for CRNAs. The agency said it would request comment on whether there are current anesthesia care access issues for particular states or VA facilities and whether permitting CRNAs to practice to the full extent of their advanced authority would resolve these issues.

Timely Care

VA announced its intentions, through a proposed rule, to grant full practice authority to four APRN roles last May. “Advanced practice registered nurses are valuable members of VA’s health care system,” Shulkin said after adoption of the final rule. “Amending this regulation increases our capacity to provide timely, efficient effective and safe primary care, aids VA in making the most-efficient use of APRN staff capabilities and provides a degree of much-needed experience to alleviate the current access challenges that are affecting VA.”

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

The American Nurses Association (ANA), on the other hand, celebrated the change—as far as it went—but challenged VA’s basis for denying expanded practice for CRNAs.

“This rule puts veterans’ health first and will help improve access to the timely, effective and efficient care they have earned,” Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, responded. “However, ANA is concerned with the final rule’s exclusion of CRNAs, which is solely based on the VA’s belief that there is no evidence of a shortage of anesthesiologists impacting access to care. We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system.

As the nation’s largest employer of nurses, VA employed about 5,769 APRNs, as of July 2016 among its workforce of more than 93,000 nurses.

The AANA argued that the VHA independent assessment ordered by Congress and published in 2015 contradicts the VA’s rationale, “identifying numerous access problems such as delays in cardiovascular surgery for lack of anesthesia support, rapidly-increasing demand for procedures requiring anesthesia outside of the operating room and slow production of colonoscopy services in comparison with the private sector.”

The group maintained that, by granting full practice authority to CRNAs, VHA would be able to make full use of more than 900 CRNAs already practicing in VHA facilities, increasing anesthesia services and veterans’ access to care without additional federal funding.

“It does seem that perhaps politics, personal agendas or favoritism may have gotten in the way of sound decision-making with regard to this important VA issue,” Nimmo posited. “Hopefully that’s not the case; the VA will review the evidence and reconsider its decision, and a final rule will be published that better serves our nation’s veterans.”

The VA, for its part, pointed out that 104,256 comments against granting full-practice authority to CRNAs had been received. It also noted that the ASA, which lobbied heavily against VA CRNAs having full-practice authority, established a website to facilitate comments against the CRNAs, which actually provided the language to use.

“These comments were not substantive in nature and were akin to votes in a ballot box,” the VA stated in a Federal Register summary. “The main argument against the VA CRNAs was that, by granting CRNAs full-practice authority, VA would be eliminating the team based concept of care in anesthesia, which is currently established in VA policy via VHA Handbook 1123, Anesthesia Service.”

The agency said it rejected that argument, instead making its decision on the basis “that evidence exists that there is not currently a shortage of anesthesiologists that critically impacts access to care, and therefore VA agrees with the sentiment of this argument.”