VA Proposes Independent Status for All Advanced Practice RNs

September 13, 2013

The Veterans Health Administration (VHA), the largest integrated health system in the country, is proposing to let its 3600 advanced practice registered nurses (APRNs) work independently, even in states that require physician oversight of these clinicians.

This freedom would entail diagnosing illness, ordering and interpreting tests, prescribing medications, and admitting patients to the hospital — responsibilities traditionally relegated to physicians.

APRNs include nurse practitioners (NPs), certified registered nurse anesthetists, certified nurse-midwives, and clinical nurse specialists. Granting them independent status will "help meet the growing demand for healthcare services," according to a VHA spokesperson who requested her name not be used.

The VHA is developing a veritable declaration of independence for APRNs in the form of a new "nursing handbook." A draft version of the handbook says that under the federal supremacy clause of the constitution, the Veterans Administration (VA) "may determine the elements of practice of its nurses, without regard to individual state practice acts," except for prescribing controlled substances.

The VHA proposal has set off alarm bells in organized medicine, already nervous about the prospect of physicians competing with NPs. At a press conference held September 9, the president-elect of the American Society of Anesthesiologists (ASA) said independent nurse anesthetists could jeopardize the care of the nation's veterans.

"Unfortunately, there's become a notion that you can take physician extenders and actually replace physicians [with them]," said Jane Fitch, MD, a former nurse anesthetist. "I'm here you to tell you from a personal perspective, we can't do that."

The training of anesthesiologists far exceeds that for nurse anesthetists in both duration and depth, said Dr. Fitch. That counts in an emergency.

"Surgical anesthesia can still be dangerous," she said. "Complications can occur that require medical interventions. We can never be too well-educated or too well-trained to function in this environment."

As proof of the need for physician supervision, the ASA points to a study published in Anesthesiology in 2000. It reported that mortality and failure-to-rescue rates were highest for patients who underwent operations without an anesthesiologist providing direction, according to the ASA.

Dr. Fitch also warned that the VHA wants to require APRNs to practice on their own whether they want to or not. She cited a VHA "frequently asked questions" document that states, "if a current APRN does not want to attain independent status they would not be able to practice as an APRN in the VHA." The document describes a process in which APRNs apply for practice privileges at VA facilities, just as physicians and dentists do.

"No Provider in the VA System Is an Island"

The VHA is not pioneering the concept of independent status for APRNs. It cites a 2011 report from the Institute of Medicine titled "The Future of Nursing," which recommended removing scope-of-practice barriers so that APRNs can practice to the full extent of their education and training. The institute's report said that in ideal regulatory framework, state nursing boards would "license APRNs as independent practitioners with no regulatory requirements for collaboration, direction or supervision." Such measures are important, the report said, to bolster a shorthanded primary care workforce.

If the VHA does approve independent status for APRNs, its decision will be widely felt. The VHA treats more than 8 million veterans each year in 152 medical centers and nearly 1400 community-based outpatient clinics, community living centers, and other facilities.

The ASA argues that independent practice for APRNs, as envisioned in the proposed VHA nursing handbook, runs counter to an existing agency handbook on anesthesia. In a recent letter to the VA, Dr. Fitch and ASA President John Zerwas, MD, write that the anesthesia handbook advocates a team approach that takes into account the training and licensure of all clinicians. "Most states require some level of physician involvement in the delivery of anesthesia care," they write. The new nursing handbook would effectively eliminate "physician-nurse team-based coordinated care."

The VHA spokesperson disagrees with the ASA assessment. The proposed nursing handbook and APRN policy, she told Medscape Medical News, support the team model of care. Furthermore, the anesthesia handbook does not require physicians to supervise nurse anesthetists, she said.

The American Association of Nurse Anesthetists (AANA) also stresses that independence does not mean the demise of teamwork.

"No provider in the VA system is an island," said Frank Purcell, senior director of federal governmental affairs at the AANA, in an interview with Medscape Medical News. "Every professional works as part of a system."

The AANA takes issue with the ASA's claim that most states require a physician role in anesthesia. It says 40 states do not mandate that nurse anesthetists work under physician supervision in their nursing or medical board statutes, and 49 states do not require anesthesiologists to be involved in a nurse anesthetist's patient care in any way. Seventeen states have opted out of a Medicare requirement for physician oversight of these clinicians. Furthermore, nurse anesthetists have practiced independently in the armed services for more than a decade.

Purcell defended the ability of nurse anesthetists to practice safely without physician oversight. He cited a study published in Health Affairs in 2010 reporting that patient outcomes were the same whether anesthesia services were provided by physicians, nurse anesthetists overseen by physicians, or nurse anesthetists by themselves.

"Their safety record is impeccable," he said.

The VHA policy on APRNs and the nursing handbook has been taking shape since at least 2011, according to annual reports issued by the VHA's Office of Nursing Services. The agency spokesperson told Medscape Medical News that the proposed policy is "currently being reviewed and vetted for a regulatory effort." Only when the VHA nails it down will the nursing handbook be published, she said.

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