During the last week of May, the Department of Veterans Affairs (VA) released a proposal that would give full practice authority to advanced practice registered nurses (APRN) who work for the VA. Under the new rule, nurses would be allowed to practice without physician supervision, regardless of state law, as long as they are within the scope of VA employment.
This would give nurses the power to diagnose and manage patients with acute and chronic illnesses. This includes prescribing medications and ordering and interpreting diagnostic tests among other things.
A History of Long Wait Times
In a report published in March 2016, an audit from the Government Accountability Office (GAO) found that not all newly enrolled veterans were able to access primary care. Of the 180 new enrollees in the GAO’s review, 60 of them had not seen a healthcare provider by the end of the audit. Nearly half of them did not get access to care because VA medical staff did not schedule these veterans appointments in accordance with policy.
According to the GAO, veterans have to wait anywhere from 22-71 days to see a primary care provider.
For the 120 new enrollees that did get to eventually see a primary care provider, they had to wait on average for 22 to 71 days from the day they made the request. For twelve veterans, they had to wait over 90 days.
Expanding Nurses’ Scope of Practice
With the proposed rule changes, the VA is hoping that it will help increase access to primary care providers for veterans. In a statement released shortly after their proposal, VA Under Secretary for Health, Dr. David J. Shulkin says, “The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future.”
The new rules would subdivide APRNs into four categories:
- Certified nurse practitioner
- Certified registered nurse anesthetist
- Clinical nurse specialist
- Certified nurse-midwife
Dr. David J. Shulkin says that the policy change will make sure the VA has the “authority to address staffing shortages in the future.”
The VA would provide criteria, including certain training requirements, to allow these nurses to have full practice authority, and then define the scope of practice for each nurse category.
All Those in Favor…
There are already 21 states and the District of Columbia that have given their APRNs full practice authority, allowing them to be able to diagnose and evaluate patients, prescribe medications and more, without the supervision of a physician. With current and future physician shortages looming, more states will surely follow suit.
Nurses in military hospitals have had full practice authority for years, managing and diagnosing patients and more.
Of the VA’s 93,000 nurses, 6,500 of them have advanced training and would see their scope of practice expanded. The VA is subject to a physician and nursing shortage and is currently trying to hire 3,800 doctors. They are also short some 8,700 registered nurses.
About 6,500 APRNs would have their duties expanded under the policy change.
There are 60 organizations backing the proposal including the American Nurses Association (ANA). In their statement, they said the “ANA applauds the proposal as a major step in removing barriers that prevent APRNs from providing a full range of health care services.”
Cindy Cooke, president of the American Association of Nurse Practitioners (AANP) also supports the proposal saying, “Veterans stand to significantly benefit from this essential VA policy update.”
Those Opposed…
Not everyone feels the same way about the proposed rule change. Nurses have a significantly less amount of education and training compared to doctors. Veterans often have multiple chronic conditions and nurses lack the skills to diagnose complex illnesses without the opinion of a physician.
Doctors argue that nurses lack the training and skills administer anesthesia and diagnose complicated illnesses themselves.
They argue that though military nurses can practice without supervision from a doctor, active injured soldiers and veteran health is different. When the military nurse has a question or is not sure, they still get the doctor’s opinion.
Dr. Jane Fitch, former president of the American Society of Anesthesiologists (ASA) shared her concerns saying, “When you have a veteran on the operating table with multiple medical conditions, seconds count.” Fitch continued, “All those years of education and training can make a difference in life or death.”
The Board Chair of the American Medical Association (AMA) has stated that he believes that the new rule change would “significantly undermine the delivery of care within the VA.”
Less Training, but More Responsibility
In the VAs proposed policy change, CRNAs would have the authority to administer anesthesia. However Dr. Daniel Cole, current president of the ASA doesn’t support the policy change saying “there is no shortage of physician anesthesiologists in the VA.”
Compared to doctors, nurses have about half the number of years education and less than 20% of the number of clinical hours. Do they have enough skill to make life or death decisions?
Certified registered nurse anesthetists only have about half the education and less than one-fifth the training of an anesthesiologist. An anesthesiologist has 12 to 14 years of education and about 15,000 clinical hours of training. CRNAs only have an average of 2,500 clinical training hours. Won’t replacing these doctors lower the standard of quality of care for our veterans?
The Bottom Line
Our veterans need to have access to high-quality healthcare. It seems that expanding the scope of nurses will help do that. If this policy change gets approved, will we continue to see this “nurse-only” model become the new normal?
After all, 21 states and the District of Columbia have already had full practice authority for years. With a physician shortage in the midst, will this policy decision lead to a precedent that ends up helping or hindering the quality of patient care for not only veterans but for every citizen in the United States?
