Doctors, nurses divided over VA’s final rule on APRNs

Veterans affairs sign
The VA will allow three categories of APRNs to practice independently. Image: JeffOnWire / CC BY 2.0

Just as the original proposal did, the Department of Veterans Affairs' final decision to expand the scope of practice of most advanced practice registered nurses (APRNs) who work for the federal agency has divided doctors and nurses.

The VA today published a final rule (PDF) in the Federal Register that will amend its regulations to permit full practice authority for three types of APRNs, a change made to give veterans greater and more timely access to healthcare.

Specifically, the VA will allow three categories of APRNs—certified nurse practitioners, clinical nurse specialists and certified nurse-midwives—to practice independently. A fourth category—that of certified registered nurse anesthetists (CRNAs)—is not included under the final rule, but the federal agency is asking for comments indicating it could include this group in future rulemaking.

RELATED: VA’s final rule gives most APRNs full practice authority

The rule, which authorizes most APRNs to provide primary healthcare and other services to the full extent of their education and abilities without the clinical supervision of physicians, was cheered by organizations that represent APRNs but has disappointed some physician groups.

The American Association of Nurse Practitioners (AANP) was among the groups that campaigned aggressively to expand the authority of more than 5,000 nurse practitioners working in VA facilities nationwide. "This final rule is a critical step for America's veterans to be able to obtain timely, high-quality care in the Veterans Health System,” AANP president Cindy Cooke said in an announcement.

Not everybody was happy with the VA’s change, which was opposed by the American Medical Association (AMA).

“We are disappointed by the VA’s decision today to allow most advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law. This part of the VA’s final rule will rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system,” said AMA President Andrew Gurman, M.D., in an announcement. “Providing coordinated, physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country’s veterans, especially given the highly complex medical care that veterans often require.”

The groups will continue to battle over the role of CRNAs, which was particularly controversial. Cooke said her group trusts that the VA will propose a plan to include CRNAs in the provision in the near future. The American Nurses Association said it was pleased with the final rule, but disappointed the VA failed to extend full practice authority to CRNAs. ANA President Pamela F. Cipriano, R.N., said the decision was based solely on the “VA’s belief that there is no evidence of a shortage of anesthesiologists impacting access to care.”

On the other hand, Gurman said he was pleased the final rule “continues to recognize the critical need for collaboration among physicians and nurse anesthetists to ensure patient safety when delivering anesthesia care.” The American Society of Anesthesiologists (ASA), which launched a campaign saying that replacing physician anesthesiologists with nurse anesthetists would reduce the standard of care for veterans, said it was gratified the VA will maintain the physician-led, team-based model of care.

“This was the right decision for our nation’s veterans and for safe patient care,” ASA President Jeffrey Plagenhoef, M.D., said in an announcement. “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.”

The proposed rule, which was issued last May, attracted an unprecedented number of comments from veterans, healthcare providers and the public, a record for VA-related issues as well as a record for the most comments posted in 2016.

The VA issued the final rule Tuesday, effective 30 days after publication, with a 30-day comment period. The VA proposed expanding the scope of practice for APRNs after two years of turmoil that began when an investigation into allegations that a Phoenix Veterans hospital used a secret waitlist to cover up treatment delays revealed a nationwide problem of veterans dying while waiting months for care.