- The Department of Veterans Affairs (VA) will now give some advanced practice registered nurses full practice authority in order to boost care access and quality of care. However, certified registered nurse anesthetists will not benefit from expanded authority.
In a final ruling, the VA stated that it will permit certified nurse practitioners, clinical nurse specialists, and certified nurse-midwives to provide advanced nursing services without physician oversight when they are working within the scope of their VA employment.
The VA intends for the expanded practice authority to standardize healthcare for veterans, increase timely care access, and improve care quality.
“Advanced practice registered nurses are valuable members of VA’s healthcare system,” stated David J. Shulkin, MD, VA Undersecretary for Health. “Amending this regulation increases our capacity to provide timely, efficient, effective and safe primary care, aids VA in making the most efficient use of APRN [advanced practice registered nurse] staff capabilities, and provides a degree of much needed experience to alleviate the current access challenges that are affecting VA.”
Healthcare stakeholders recently slammed the VA for care access barriers, such as long wait times, but the federal department intends for the increased practice authority to alleviate access challenges.
In April, the Government Accountability Office (GAO) found that 60 out of 180 veterans had not seen a provider for primary care and about half of them were unable to access primary care services because some VA medical center staff were unable to schedule appointments in accordance with policy.
For veterans that did see a provider, the wait times were between 22 to 71 days despite some medical records indicating “zero-day” wait times.
Another recent report from the Washington Post attributed veteran care access barriers to recent shortages of clinicians and other providers in the VA. About 6,000 nurses, physical therapists, medical doctors, psychologists, and physician assistants left their VA job in 2011 and that number increased to 7,734 by 2015.
The recent practice authority expansion may help to overcome care access and quality challenges at the VA.
The final rule states:
“This rulemaking increases veterans’ access to VA healthcare by expanding the pool of qualified healthcare professionals who are authorized to provide primary healthcare and other related healthcare services to the full extent of their education, training, and certification, without the clinical supervision of physicians, and it permits VA to use its healthcare resources more effectively and in a manner that is consistent with the role of APRNs [advanced practice registered nurses] in the non-VA healthcare sector, while maintaining the patient-centered, safe, high-quality healthcare that veterans receive from VA.”
Expanding advanced practice registered nurse services should also help to standardize care across the VA’s healthcare system. Care standardization should allow the federal department to “provide timely, efficient, and effective primary care services, as well as other services.”
The rule also aims to increase patient access to care in medically-underserved areas and decrease wait times.
Additionally, the final rule may help to alleviate healthcare employment challenges at the VA, including recruitment, hiring, and retention. A 2015 RAND survey found that about 38 percent of VA general facility Chief of Staffs reported recruiting and hiring problems with advanced practice providers.
Another 50 percent said they faced similar recruiting and hiring issues with clinical specialists.
The top reported recruitment and hiring barriers for advanced practice providers was non-competitive wages (72 percent of advanced practice providers), followed by human resources process (42 percent), geographic location of facility (35 percent), and lack of qualified applications (26 percent).
VA Chiefs of Staff also experienced trouble retaining advanced practice providers. About half stated that they had problems retaining nurses, including clinical specialists.
The top reason for retention challenges were dissatisfaction with supervision or management support (61 percent of advanced practice providers). Although, about 36 percent of advanced practice providers were also dissatisfied with compensation.
The final rule may not address the specific healthcare employment iisues plaguing the VA and advanced practice providers, the federal department noted. However, expanded advanced practice registered nurse authority may make the system more efficient, making more resources available to resolve employment issues.
While some advanced practice registered nurses will benefit from the rule, the VA decided not to include certified registered nurse anesthetists (CRNAs) in the authority expansion. The federal department found no care access issues for anesthesia care and, therefore, did not expand practice authority.
“CRNAs provide an invaluable service to our Veterans,” Shulkin said. “Though CRNAs will not be included in VA’s full practice authority under this final rule, we are requesting comments on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking. In the meantime, we owe it to Veterans to increase access to care in areas where we know we have immediate and broad access challenges.”
The VA also noted that federal law will supersede state or local regulations on advanced practice providers and full practice authority. Currently, only 21 states plus Washington, DC have full practice status for nurse practitioners, according to the American Association of Nurse Practitioners.
In response to the VA ruling, the American Medical Association (AMA) voiced disappointment. The industry group claimed that the expanded practice authority will “rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system.”
The AMA favors physician-led team-based patient care as the most efficient way to improve care quality and reduce healthcare costs. However, the VA’s new rule would work against this method.
The VA’s final rule will go into effect on Jan. 13, 2017. Although, the federal department will accept comments on full practice authority for CRNAs by the same date.