The Department of Veterans Affairs (VA) has passed a rule allowing three types of advanced practice registered nurses (APRNs)—certified NPs, clinical nurse specialists, and certified nurse midwives (CNMs)—to practice to “the full extent of their education, training, and certification” without physician supervision. The rule applies throughout the VA's national network of medical centers, and takes precedence over individual state laws regulating the scope of APRN practice. However, certified registered nurse anesthetists (CRNAs) were not granted the same privileges.
APRNs covered by the rule are now able to conduct physical examinations; diagnose, treat, and manage acute and chronic diseases; order laboratory and imaging studies; prescribe medications; and make referrals. CNMs are authorized to conduct gynecologic examinations, provide prenatal and postnatal care, and assist with childbirth and the care of newborns.
The rule, which became effective January 13, has been embraced by nursing organizations, including the American Nurses Association and the American Association of Colleges of Nursing (AACN), whose board chair, Juliann Sebastian, said in a statement, “Currently, AACN's member institutions are educating nearly 90,000 APRN students…. Whether in deployment abroad or in clinics at home, APRNs are critical to ensuring the health of our nation's service members and veterans.” Both organizations, however, continue to urge the same privileges for CRNAs.
The VA currently serves over 9 million veterans; as of December 2016, about 7% of patients were waiting for an appointment for 30 days or longer. Following the 2014 scandal that eventually led to the resignation of then Secretary Eric Shinseki, the VA made provision of timely care a priority. Granting full practice authority to the designated APRNs is a step in that direction, says the VA, because it “increases veteran access to needed VA health care, particularly in medically underserved areas, and decreases the amount of time veterans spend waiting for patient appointments.”
The rule has also been lauded by the American Hospital Association, and by various veterans’ organizations, including American Veterans, Paralyzed Veterans of America, and Military Officers Association of America. In an opinion piece in Forbes magazine, retired senator Bob Dole, a World War II veteran, wrote that the rule is “an important step in the right direction. In fact, it's more than a step; call it a ‘leap.’ Our veterans deserve the very best, most timely health care services the VA can provide, and [this] is a logical, cost-effective, and proven safe way for that to happen.”
CRNAs were targeted for exclusion from the rule by the American Society of Anesthesiologists (ASA), which, according to the VA, “lobbied heavily against VA CRNAs having full practice authority.” The VA did not agree with the ASA's argument that expanding the scope of practice for CRNAs would compromise team-based care, and generally dismissed the ASA's arguments as unsubstantiated. It concurred, however, with the organization's position that the VA has adequate service coverage by physician anesthesiologists, based on data compiled by VA analysts. Still, the VA left the door open to including CRNAs in a future rule revision should there be “access issues or other unconsidered circumstances” warranting that, and emphasized that excluding them this time was not based on their “inability to practice to the full extent of their professional competence.” A limited comment period was reopened in January to solicit evidence of access problems in anesthesiology. —Dalia Sofer