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December 28, 2016
On December 14, the Department of Veterans Affairs (VA) published a final rule amending its medical regulations to expand the scope of practice for certain Advanced-Practice Registered Nurses (APRNs) at VA facilities. The VA believes the rule, which becomes effective January 14, 2017, will make it easier for veterans to be seen by medical professionals by increasing the number of available primary-care providers.
Of the 93,500 registered nurses, licensed practical nurses and nursing assistants employed by the Veterans Health Administration (VHA), more than 5,700 are APRNs, hired to work on primary-care teams or in settings with provider shortages.
This final rule applies to APRNs who have:
- Completed a nationally-accredited, graduate-level educational program that prepares them for one of the three APRN roles of Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS), or Certified Nurse-Midwife (CNM);
- Passed a national certification examination that measures knowledge in one of the APRN roles described above; and
- Obtained and maintains a license from a State licensing board in one of three recognized APRN roles described above.
The final rule permits qualifying APRNs to perform the following services without the clinical oversight of a physician, regardless of State or local restrictions, when working within the scope of their VA employment:
- Take comprehensive histories, provide physical examinations and other health assessment and screening activities, diagnose, treat and manage patients with acute and chronic illnesses and diseases;
- Order laboratory and imaging studies and integrate the results into clinical decision making;
- Prescribe medication and durable medical equipment; and
- Provide a range of primary healthcare services to women, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and care of a newborn.
The full practice authority of an APRN is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801 et seq., and that APRN's State licensure on the authority to prescribe, or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy.
Although the rule as initially proposed included Certified Registered Nurse Anesthetists (CRNAs), the final rule does not expand their scope of practice based on input from the American Society of Anesthesiologists (ASA) who opposed the VA's proposal to expand the scope of practice for CRNAs. The ASA felt that a physician anesthesiologist should always be present in the operating room in case of a medical emergency, noting that physician anesthesiologists receive 12 to 14 years of education, including medical school, and 12,000 to 16,000 hours of clinical training, while CRNAs have about half the education and almost 2,500 hours of clinical training, according to the ASA.
The VA appears to have been swayed by comments, stating: “VHA believes that VA does not have immediate and broad access problems in the area of anesthesia care across the full VA healthcare system that require full practice authority for all CRNAs,” the rule said. The VA will take comments on that decision until January 14, 2017.
Stakeholders expressed mix reactions to the final rule.
In a statement, Cindy Cook, president of the American Association of Nurse Practitioners, called the final rule "a critical step for America's veterans to be able to obtain timely, high-quality care in the Veterans Health System."
In contrast, American Medical Association (AMA) President Andrew Gurman said that the group is "disappointed by the VA's decision ... to allow most APRNs within the VA to practice independently of a physician's clinical oversight, regardless of individual state law." He added, "This part of the ... 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. Providing coordinated, physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans."
However, AMA applauded VA for removing nurse anesthetists from the rule. "AMA is pleased that the VA final rule continues to recognize the critical need for collaboration among physicians and nurse anesthetists to ensure patient safety when delivering anesthesia care," Gurman said.
The ASA also praised VA for excluding nurse anesthetists from the final rule. ASA President Jeffrey Plagenhoef said, "This was the right decision for our nation's veterans and for safe patient care."
The Institute of Medicine was at the forefront of those recommending that APRNs be granted “full practice authority,” claiming that countless studies have documented that APRNs provide safe and effective care at lower costs than physicians. The fight has been waged in various states, 22 of which have granted full scope of practice to APRNs.
This will continue to be a divisive issue among the healthcare community, and many on both sides will be closely monitoring the results of this decision by the VA hoping for data that will support their position for or against expanded scope of clinical responsibility. In either case, decisions based on outcomes data are likely to have far-reaching effects on our healthcare delivery system in the coming years.