Nurses, Veterans Back Independent Practice for Advanced RNs

Troy Brown, RN

June 29, 2016

A group of professional nursing associations and military organizations held a news briefing yesterday to throw their support behind a proposed rule by the Department of Veterans Affairs (VA) that would permit advanced practice registered nurses (APRNs) employed by the VA to practice "to the full extent of their education, training, and certification, without the clinical supervision of physicians," according to a statement in the federal register.

The proposed rule was published on the federal register on May 25. The VA has made the proposal available for comment in an effort to increase veterans' access to care.

To date, more than 44,000 people have submitted comments, more than six times the total number of comments submitted for previous rules, according to a release from the American Association of Nurse Anesthetists (AANA).

Although organized medicine has voiced strong opposition to the rule, the nursing and veterans' groups at the briefing were ardently behind the plan.

"Healthcare is one of the things our veterans were promised when they raised their right hands to serve their country," CMSGT Robert L. Frank, USAF (ret), chief executive officer of the Air Force Sergeants Association, said at the news briefing. "More than 80% of those who served in the military were enlisted, and many rely on VA healthcare to take care of them. The waiting is unacceptable. We're excited about this rule to allow the 6000 APRNs currently employed by the VHA [Veterans Health Administration] to be used to their full potential. Let them serve our veterans."

The AANA, the American Association of Nurse Practitioners (AANP), the American Nurses Association (ANA), the American Association of Colleges of Nursing (AACN), the Military Officers Association of America, and the Air Force Sergeants Association participated in the news briefing.

Anesthesia Provision by Nurse Anesthetists Not New

Nurse anesthetists cared for wounded soldiers on the battlefields during the American Civil War and have been the primary anesthesia care providers "on the front lines of every US military conflict since World War I," according to the AANA.

"Our veterans are waiting too long to get the healthcare they have earned and they deserve. For years now, it's been clear to all of us that the VA healthcare system has tried, and despite all their efforts, we still need access to services for our veterans ― we're just not getting it," Juan Quintana, DNP, MHS, CRNA, president, AANA, who also served in the Air Force Reserves, said at the news briefing. "In independent VA assessment indicated that anesthesia services and access to those services was one of the limiting factors...for veterans getting surgical care, sometimes waiting for months to get those services.

"In terms of access, CRNAs have been administering anesthesia for 150 years. We provide services in underserved areas, in ruralities, [and] in some VAs without anesthesiologist involvement, [and] in addition to that, in the forward surgical teams that provide services to our soldiers who are in harm's way," Dr Quintana said.

"Time for Evidence to Trump Politics"

"It's time for evidence to trump politics when it comes to the health of our veterans. And there's no evidence for the arguments of the groups opposing the rule ― all baseless rhetoric," Dr Quintana said. "Our initial review of the comments submitted thus far indicates wide-reaching support for the rule from veterans and healthcare providers alike ― roughly two thirds of the comments submitted ― and we want to encourage others to submit comments and let their voices be heard."

"Leading authorities, such as the National Governors Association, the Institute of Medicine, and the Federal Trade Commission, recognize that barriers to practice for APRNs impede healthcare access and quality. What we are advocating is that policy aligns with evidence," Jane M. Kirschling, PhD, RN, FAAN, dean and professor, School of Nursing, and director of interprofessional education, University of Maryland, in Baltimore, and American Association of Colleges of Nursing, explained.

"When the more than 70,000 APRN students enrolled in AACN member nursing schools enter the workforce, allowing them to practice to the full extent of their education and training will serve as a strong incentive for these highly skilled providers to seek employment at VA facilities," Dr Kirschling added.

"In the Navy, we would never train a sailor ten skills, then limit them to using only three. It makes no sense. No one would do that. But that's what illogical and wasteful practice limitations on highly skilled advanced practice nurses do. Our veterans need all the skills [APRNs] can provide them," Kathryn Beasley, CAPT (Ret), USN, PhD, FACHE, said. Dr Beasley served as a Navy nurse for 30 years, working with nurse practitioners, nurse anesthetists, and other APRNs. She supports the proposed change on behalf of the 390,000 members of the Military Officers Association of America.

"I personally know the value and contribution that APRNs can make to serve our country's veterans," Mala J. Weston, PhD, RN, FAAN, chief executive officer, ANA, said. Dr Weston formerly worked at the VHA as deputy chief officer. "Our veterans deserve the best care that this country can provide, and that requires having APRNs practicing to the full extent of their education and training. We know that when there are not enough nurses, patient mortality goes up,” she added.

American Medical Association, Other Physician Groups Disagree

According to the AANA, more than 60 organizations, including veterans' groups, the American Association of Retired Persons, and 80 Democratic and Republican members of Congress, support the proposed rule.

Not everyone agrees with the proposal, however. The American Medical Association (AMA), the American Society of Anesthesiologists (ASA), and other physician organizations have issued statements opposing the rule.

"With over 10,000 hours of education and training, physicians bring tremendous value to the healthcare team. All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine," the AMA said in a statement.

"From patient-centered medical homes to some of the nation's largest healthcare systems, physician-led interprofessional team-based healthcare has proven to be a successful model in the delivery of healthcare. The nation's top healthcare systems rely on physician-led teams to achieve improved care and patient health while reducing costs. We expect the same for our country's veterans, and look to these systems as evidence that physician-led, team-based models of care are the future of American healthcare," the AMA statement continued.

The ASA also objects strongly to the proposed change.

"ASA strongly opposes the inclusion of the surgical/anesthesia setting and nurse anesthetists in the VHA Nursing Handbook. The leading experts on surgical anesthesia care in the VA, the Chiefs of Cnesthesiology, have informed VA leadership that the new policy 'would directly compromise patient safety and limit our ability to provide quality care to veterans,' " the ASA said in a statement.

The public is invited to submit comments online on the proposed rule.


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