A proposed Department of Veterans Affairs rule change that would expand the role of nurse practitioners in caring for patients in VA facilities has set off heated verbal volleys between national physicians and nurses groups while generating more than 16,700 comments on the federal government’s eRulemaking website as of Tuesday.
Designed to reduce delays for veterans seeking medical care and to
address personnel shortages within the VA system, the proposed rule
would allow advanced-practice registered nurses to make diagnoses,
prescribe medications and interpret diagnostic tests. The rule breaks
down the nurse practitioners, who have advanced medical degrees, into
four roles: certified nurse practitioners; clinical nurse specialists;
certified registered nurse anesthetists, or CRNAs; and certified nurse
In a prepared statement, VA Undersecretary for Health David Shulkin
said: “At this time, the VA is not seeking any change to [Veterans Health Administration] policy on
the role of CRNAs, but would consider a policy change in the future to
utilize full practice authority when and if such conditions require such
Juan Quintana, president of the American Association of Nurse
Anesthetists, told AMI Newswire Tuesday that the limitations on nurse
practitioners vary tremendously from state to state and that a
consistent federal rule would better ensure excellent care for veterans.
“I think that the VA is doing the right thing by working to standardize
services among all VA hospitals,” said Quintana, who added that the rule
might take effect by the end of the year.
He pointed to a study published in the June issue of the journal Medical Care
that he said supports the expansion of the nurse practitioner role. The
study concluded that practice limitations and physician supervision
requirements that many nurse practitioners now work under do not
increase anesthesia safety among patients.
Quintana said the study also found that such
restrictions reduced patients’ ability to receive high-quality health
care while increasing overall health care costs.
Quintana said that, once the advanced-placement nurses begin to provide
services to veterans, they will discover more medical issues among their
patients, leading to a greater demand for surgical services overall,
including those provided by CRNAs.
Physicians, however, see the proposed rule change as a life-endangering threat to the medical care of veterans.
Dr. Daniel Cole, president of the American Society of Anesthesiologists,
said last week during a press conference that the change would abandon a
proven team approach to health care involving physician
anesthesiologists and nurses.
The president of the National Association of VA Physicians and Dentists,
Samuel Spagnolo, said during the same press briefing that the rule
change would provide a lower level of patient care – one lacking in
physician oversight. And he emphasized the need for seasoned, skilled
professionals in the care of veterans.
“Patients may look to be doing well, but then a few seconds later they are at death’s doorstep,” Spagnolo said.
He said of the proposed rule: “It is so filled with jargon that it will take 10 Harvard lawyers to decipher it.”
Physicians opposed to the rule emphasize that physician
anesthesiologists receive 12 to 14 years of education and training,
including up to 16,000 hours of clinical training. In contrast, CRNAs
get half as many years of education and only about 2,500 hours of
training, they said.
Quintana described the position of physician groups as an effort to
protect their professional turf. National organizations representing
nurses point out that the American military, 21 states and the District
of Columbia have allowed expanded roles for advanced-placement nurses in
“It’s interesting that the same doctors who argue that they need to be
involved in the care of our military veterans don’t insist on being
assigned to the front lines during military actions to care for soldiers
horribly injured during battle, leaving this up to CRNAs to handle,”
Some members of Congress also seem troubled by the proposed rule.
VA proposes to eliminate the requirement for physician involvement in
anesthesia delivery, striking the physician-nurse ‘team’ model,” Rep.
David Jolly (R-Fla.) wrote on his Facebook page. “I am deeply concerned
that this change by the VA will compromise the quality and safety of
anesthesia care administered to our veterans.”
Shulkin,However, however,Shulkin the undersecretary told the Washington Post
last week that “I’ve looked at the data in the VA, and I do not assess
that we have an access problem in anesthesia. We are using team-based
The public comment period on the proposed VA rule concludes on July 25.