On May 25, 2016, the Department of Veterans Affairs (VA) proposed to make some changes in the way it provides veteran care in the United States. The largest integrated health care system in the United States, the VA proposed a rule that would give full practice authority to Advanced Practice Registered Nurses (APRNs) when they are working in VA facilities.
The VA suggested this proposal to decrease the wait times that veterans currently have to receive medical care. In a statement, VA Under Secretary for Health David J. Shulkin, MD, said, “The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future. Implementation of the final rule would be made through the VHA [Veterans Health Administration] policy, which would clarify whether and which of the four APRN roles would be granted full practice authority. At this time, the VA is not seeking any change to VHA policy on the role of CRNAs [Certified Registered Nurse Anesthetists], but would consider a policy change in the future to utilize full practice authority when and if such conditions require such a change.”
Currently, the four APRN roles are Certified Nurse Practitioners (CNP), CRNAs, Clinical Nurse Specialists (CNS), and Certified Nurse-Midwives (CNM).
According to the VA, there are about 505,000 veterans who have been waiting 30 days to get the medical appointments and care that they need and another 300,000 are waiting between 31 and 60 days to get health services. The goal of this proposal is to greatly decrease these waiting times.
The American Medical Association (AMA) issued its views on the VA’s proposal in a statement shortly after. “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,” says Stephen R. Permut, MD, JD, board chair of the AMA. “We feel this proposal will significantly undermine the delivery of care within the VA.”
According to a national survey released by Veterans Deserve Care, a grassroots campaign led by the American Association of Nurse Practitioners (AANP), 88% of Americans support the VA’s proposal, and the number climbs even higher to 91% in support when the people surveyed had a veteran in their household.
So what do nurses and nurse groups say about the proposal? We approached some to get their perspectives on this controversial proposal.
Making Real Change
The nurses we connected with believe that the proposal, if adopted, could make real positive changes for the lives of many veterans.
“We don’t see it as controversial. We feel like it is a really good solution. It is a no-cost, no-delay solution for the VA to utilize advanced practice registered nurses into the full schedule of their education and clinical training,” says Cindy Cooke, DNP, FNP-C, FAANP, president of the AANP. For more than 12 years, Cooke has provided care exclusively to active duty as well as retired military members and their families. “[APRNs] do provide clinical assessments as well as order and interpret them,” she continues. “We make diagnoses. We initiate and prescribe treatment plans, including prescribing medications if they are indicated—all of that is to promote patient-centered care.”
What the proposed rule would really do, Cooke says, is to standardize the care across all the VA facilities throughout the nation, regardless of where they are located geographically. Currently in 21 states and in the District of Columbia, nurse practitioners can already practice to the full scope of their educational and clinical training. “What this would do would be to standardize it across the VA in order to increase access to the expertise that nurse practitioners can provide so that we can really decrease the waiting times that our veterans currently have to go through to get appointments,” states Cooke.
“This is not new. We’re not asking for something that’s not been happening already,” says Cooke. “The VA’s proposal is really to increase access to care.”
“It is well known that many veterans routinely endure long wait times to receive needed health care. Some veterans have even lost their lives due to this terrible situation,” says Juan Quintana, DNP, MHS, CRNA. He is the president of the American Association of Nurse Anesthetists (AANA) and served for nine years in the military as an Air Force reservist. Having practiced anesthesia since 1997, Quintana is also the president of Sleepy Anesthesia, which provides anesthesia services to several hospitals in rural Texas.
“The goal of the VA’s proposed rule is to help alleviate long wait times for veterans by allowing full practice authority for all APRNs. Making full use of the expertise and abilities of CRNAs and other APRNs is a major step toward solving the wait-time problem,” argues Quintana. “For CRNAs, the rule would standardize anesthesia services across the nation’s largest health care system and bring it in line with the Army, Navy, Air Force, Indian Health Services, and Combat Support Hospitals. The Department of Defense already allows CRNAs to work without physician supervision.”
If the VA were to allow CRNAs to have full practice authority, Quintana says this would allow them to provide a patient’s anesthesia care and anesthesia-related care, without physician oversight, including planning and initiating anesthetic techniques (general, regional, and local) and sedation, providing post-anesthesia evaluation and discharge, ordering and evaluating diagnostic tests, requesting consultations, performing point-of-care testing, and responding to emergency situations for airway management.
“In order to ensure this standardization, CRNAs and other APRNs would not be limited by state or local laws in their ability to provide outstanding care to veterans,” explains Quintana. “Additionally, the rule would even ensure more effective utilization of physician anesthesiologists. Instead of needlessly supervising CRNAs, anesthesiologists would be able to do their part to help reduce dangerously long wait times for veterans by actually providing more hands-on anesthesia care to our nation’s veterans.”
According to Sarah A. Delgado, RN, MSN, ACNP-BC, a clinical practice specialist with the American Association of Critical-Care Nurses (AACN), there are many other benefits to this proposed rule. “If passed, one benefit to veterans is that by providing full scope of practice, the VA is likely to attract a larger pool of APRNs committed to providing excellent patient care. This could have a major impact in addressing the gaps in access in remote and rural areas where health care resources are scare,” she explains. “In addition, many of our veterans suffer from chronic health problems, and they need both nursing and medical care to manage these. The blend of nursing and medical expertise—that is the foundation of the APRN practice—is ideal for chronic disease management. ‘Work arounds’ often develop when APRNs are not allowed to practice to their full scope, which can delay the delivery of patient care.”
Delgado gives an example: if an APRN identifies that a patient needs a particular treatment, but has to ask that person to wait for a doctor to give the official approval, this is an inefficient use of time for the patient as well as for the entire health care team. “Maximizing APRN capabilities helps provide timely, efficient care to our veterans,” she says.
“An independent assessment of the VHA ordered by Congress and published in 2015 identified 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—that’s just in anesthesia alone. The problem in VHA facilities isn’t necessarily a shortage of qualified providers; it’s figuring out how to use existing resources, such as CRNAs and other APRNs more effectively to reduce wait times for care. The VA’s proposed rule gets right to the heart of the matter,” says Quintana.
“The benefit to APRNs would be the ability to work closely with the patient care team members—including physicians, others nurses, and technicians—to provide outstanding care to the full extent of their education, training, and abilities without physician oversight,” continues Quintana. “Unnecessary physician oversight creates delays and added cost, but does not improve quality of care or patient safety, as numerous research studies have shown. APRNs have long had an impact on ensuring quality health care for military personnel and veterans alike, and they stand ready for the opportunity to make an even greater difference once the proposed rule is finalized.”
Speaking of costs, Quintana also points out that another benefit of this proposed rule is cost efficiencies. Because the VA proposes making better use of existing resources, there would be no additional cost to the VA, the federal government, or to U.S. citizens.
Meeting the Needs of a Specific Population
Maria Olenick, PhD, FNP, RN, is the chair of undergraduate nursing at the Nicole Wertheim College of Nursing and Health Sciences (NWCNHS) at Florida International University in Miami, Florida and is married to a veteran of the U.S. Navy. She sees how the veteran population is different from that of civilians. “The training they go through, the rigid and routine structure of their daily lives, not to mention any experiences in combat—it all has an impact,” she explains. “Many have difficulty with social integration and psychological issues on top of their physical conditions.”
“The nature of nursing professionals—nurses or nurse practitioners—is to develop a holistic treatment of care,” says Olenick. “Expertly trained advanced practice nurses who specialize in caring for this particular patient population can spend the time necessary to get the patient to open up, or they can assess if the veteran needs additional care services to complement the treatment of the diagnosed condition.”
Delgado says that a lot of care that patients need can be provided effectively by an APRN practicing independently. “Many of our veterans, however, suffer from chronic mental health and physical health problems and require comprehensive inpatient and outpatient services. Their multiple needs are best met by a collaborative approach with APRNs functioning as members of an interprofessional team that includes nurses, doctors, social workers, physical/occupational/mental health therapists, and, of course, the veterans’ families and other members of their community,” says Delgado. “No one person—including an APRN, can single-handedly meet all the complex needs of this patient population.”
“APRN care is not the same as medical care provided by doctors. It is different, but it is not less than. Multiple studies demonstrate that APRN care is safe and effective and yields comparable patient satisfaction ratings,” says Delgado. “My contribution to my patients’ care is unique and of equal value to the contribution made by my physician colleagues. While large doctor groups may disagree with that statement, the doctors I’ve worked with would agree with me.”
“It is important to note that while physician groups make unsubstantiated claims about the VA’s proposed rule lowering the standard of care for veterans, there is no research evidence to support these claims,” says Quintana. “Quite in contract to the physician groups’ claims is the reality that these same doctors don’t insist on being assigned to the front lines in forward surgical teams to care for soldiers horribly injured during battle, leaving this up to CRNAs to handle. In their view, caring for our wounded warriors at the point of injury is somehow less complicated than caring for veterans stateside. If anything, anesthesia care on the front lines is the very definition of ‘complicated cases,’ and ‘emergency situations,’ and the fact that CRNAs provide the vast majority of that care without an anesthesiologist anywhere to be found only confirms what research has shown many times over: CRNAs can and do provide safe, high-quality care in any setting, including VHA facilities across the United States. No physician oversight required.”