Medscape Readers Don't See Eye to Eye on VA's Independent APRN Proposal

Laura A. Stokowski, RN, MS

Disclosures

July 07, 2016

The Proposal

On May 24, 2016, the US Department of Veterans Affairs (VA) announced a proposed rule that would grant full practice authority to advanced practice registered nurses (APRNs) across Veteran's Health Administration (VHA) facilities when practicing within the scope of their VA employment. APRNs include nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), certified nurse midwives, and clinical nurse specialists.

Under the proposed rule, most APRNs would be able to practice to the full extent of their education, training, and certification to provide care to veterans without the clinical oversight of physicians or the need for collaborative practice agreements in all 152 VA facilities nationwide. The VA believes that the regulation would ensure that they have the authority to address staffing shortages, increase access to care for veterans, and reduce their wait times for appointments. In a press release, however, the VA has stated that, at this time, it is "not seeking any change to VA 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 a change."[1]

If the overall rule is adopted, it would erase the patchwork of APRN scope-of-practice differences that currently exist within the VA. At the moment, APRNs practice under the rules of their individual state licenses, meaning that some are independent and others must be supervised. The VA's proposed rule indicates that, to date, only 21 states and the District of Columbia permit independent APRN practice. The rule would grant independent practice authority to APRNs licensed in the other 29 states, regardless of those states' regulations.

The exception to universal independent practice for the VA's APRNs concerns controlled substance prescriptive authority. Under the proposed rule, independent practice within the VA will not grant this authority to APRNs licensed in a state that restricts controlled substances prescribing. With respect to prescribing or administering controlled substances, the proposed rule will not supersede individual state law.

What does full scope mean? It means that an NP, for example, would have the independent authority to provide the following services: take comprehensive histories; conduct physical examinations and perform other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling.

The proposed rule has been posted for a public comment period that closes on July 25, 2016. To date, more than 46,000 comments about the proposed rule have been offered on that website.

A Medscape news story, "VA Plan for Independent Advanced Practice RNs Riles Physicians," described the swift opposition arising from organized medicine over the proposed rule. In just days, more than 350 comments were posted by Medscape readers, reflecting a deep, though predictable, chasm between physicians and supporters (primarily nurses and APRNs) of the proposed rule. A selection of those comments, representing both sides of the issue, is provided below. (Note: some comments have been edited for length and clarity).

Second-Rate Care?

Among the many objections raised by Medscape readers to the VA's proposed rule, the most frequent concerned the education and experience of NPs (or lack thereof) compared with physicians and the impact this would have on the safety and quality of care. Some physicians went further, calling the proposal "dangerous" and characterizing the VA as "criminal" for considering it.

The notion of an essential hierarchy among healthcare providers, with physicians at the top and nurses on the lower rungs, was evident in many physician comments. Nursing education, said one physician, "lacks basic medical science," and nursing students have a "generally lower intellect compared with those entering medical school." One physician believes that "graduating APRNs have the same clinical experience as third-year medical students at the end of the first quarter. No one in their right mind thinks that those medical students have enough experience to be let loose on the world with no supervision."

An internist commented that "the problem is that many APRNs learn online through for-profit schools. My 4 years of undergraduate work, 4 years of medical school, and 3 years of residency are not comparable to the level of APRN education, and it's a disservice to the veterans to claim they are equal." A common view, as expressed by a dermatologist, was that "APRNs do not have enough experience to even know what they don't know."

Nor was there any shortage of sarcasm; for example, a physician said, "Let's have registered nurses get doctoral degrees, plus 3 or more years of residency before practicing. Oh, wait a minute. That's called medical school."

An APRN reacted to this line of attack. "We are not asking to practice as physicians. We ask for the opportunity to serve our patients safely and effectively according to our training. I would never represent myself as anything other than an APRN. I am proud of my career." Many other APRNs responded in kind.

But an anesthesiologist remarked, "When your knowledge and experience are limited, you can't always visualize what your scope is. I work with midlevel providers and have corrected life-threatening decisions made by them numerous times. Some of the folks I have bailed out of bad decisions are the loudest at crying for independence." He continued, "I sleep well at night knowing that I accomplished a rigorous course of education and training and provide a level of safety for my patients that lesser-trained providers only delude themselves into thinking they equal."

The word "equality" was tossed around quite a bit during the discussion. Physician commenters claimed that APRNs thought that they were or wanted to be the "equal" of physicians, whereas APRNs tried to explain that they weren't seeking such equality. One NP said, "Don't confuse 'independent APRN practice' as being 'equal to' physician practice." APRN practice is different from, not inferior to, physician practice. Independence does not mean never consult, never refer, and never ask for help.

However, some physicians cried "hypocrisy," dismissing out of hand claims by APRNs that they are not trying to compete with or substitute for physicians. A general practice physician said, "APRNs are under the impression that they are able to perform a physician's job independently simply on imitation and emulation of usual orders and situations." Another claimed that the desire for independent practice is driven by "a cognitive bias in which relatively unskilled persons suffer illusory superiority, mistakenly assessing their ability to be much higher than it really is." And a pediatrician claimed that the "big issue here" is that APRNs "want equal status and decision making and probably the ability to veto medical decisions without earning the degree and experience and without accepting the ultimate responsibility."

Turf War or More?

An NP believes that there is room for everyone and related personal experience at the VA, saying, "As an NP of 20 years and the mother of a veteran who can't get the care he needs from the local VA hospital, I say that the VA needs to welcome all the help it can get. NPs are not doctors, and we don't hold ourselves out as such. We work in many places that doctors won't go. NPs often are the only healthcare providers for hundreds of miles in Central Montana. We are the providers in jails and prisons where doctors don't want to practice. We provide much of the care for the mentally ill in these settings. There is more than enough work for all of us."

Continuing this theme, another nurse recommended that disgruntled physicians should "stop finger pointing and grousing over territory they never wanted in the first place."

An internist joined the debate, saying, "There is a stark difference between a team approach and diluting the system for financial considerations. We all have a place on the team and spot at the table. Independent unsupervised work as a physician should require the education, training, and experience of a physician. This is not about turf. This is about knowledge, training, and expertise."

A nurse practicing in a rural area where physicians, who are few and far between, not infrequently refuse to accept senior citizens as patients, sees independence for APRNs as not only desirable but essential in meeting healthcare needs of the underserved. "I thought that the "Dr-God complex" had disappeared; that physicians finally understood that other members of the healthcare community share the basic desire to help people and do no harm. Nurses are not your enemy, doctors. They don't want your jobs. They don't want to render you extinct. They want to work beside you, not under you."

Becoming extinct may be exactly what some physicians fear, seeing the APRN proposal as one element of a convoluted conspiracy to push physicians out of medicine while touting NPs as the answer to the physician shortage. "It's the perfect solution to ensure the demise of private family practice," said one physician.

But an NP warns, "You docs will lose this battle because you are placing your ego and sense of entitlement before the needs of patients. In any other industry, your behavior would not be tolerated. Only in healthcare—our antiquated classist and sexist hierarchical system—do we accept such professional pouting, foot stomping, and bullying."

Good Luck Stopping It Now

More than a few physicians who commented on Medscape apparently do not realize that APRNs are already practicing independently of physicians in many settings. One such physician even claimed that "no politician would ever expect or receive care by APRNs for themselves or their loved ones."

Many other Medscape readers tried to enlighten these physicians, warning that trying to stop independent practice for APRNs is like shutting the barn door after the horse has bolted. Besides the states in which APRNs can already practice independently of physician supervision, federal programs including the US Armed Forces, Indian Health Service, and Public Health Service systems also recognize full practice authority for APRNs.

A cardiologist essentially blamed his peers for the current situation, believing that APRNs should have been under the thumb of organized medicine all along. "It was only a matter of time before this started. Physicians have been using and tolerating the incorporation of independent nurse practitioners for years, and we have not tried to control their training and use. Anesthesia groups have been hiring CRNAs so that they can monitor more operating rooms than one person could reasonably do. Now, we are fighting the same thing we have been exploiting. So good luck trying to arrest the spread now."

A family physician questioned the limits of practice for APRNs, saying, "Because no limits are defined, let's face it, APRNs are de facto physicians. Give them the degree, MD or DO, and be done with it." He continued, "I blame the American Medical Association and the American Osteopathic Association for the present debacle in medicine. It started when orthopedists ceded foot practice to podiatrists, ophthalmologists ceded refractions to optometrists, obstetricians looked the other way when midwives made a comeback, and osteopaths stopped doing manipulative therapy, leaving it to chiropractors to fill the void."

An NP likewise blames physicians, saying, "Sorry, but the beast that created a shortage of quality medical care is the medical profession. There is nobody else to blame, no invisible hand, no politician, no natural disaster."

'Our Poor Vets'

Many physicians took pains to emphasize that their opposition to independent practice for APRNs is entirely out of concern for our veterans and has nothing whatsoever to do with a threat to their profession or their livelihood.

"Why are we depriving our veterans the expertise of an MD when all other citizens in our country have access to it?" asked one physician. Another asked, "Do you want the best trained people taking care of our veterans, or do you want to settle for something significantly less than that? I believe that the people who risked their lives to keep us safe and protect the freedoms we love in our country deserve the best."

APRNs have another view of the proposal. "I applaud the VA for what they are doing for the veterans. Everyone seems to have lost the focus behind its reasoning. Veterans deserve access to care. And with wait times months out, it is a shame that providers willing and able to care for them are being limited by laws that vary state to state," said one APRN.

Resentment ran through some of the comments, with one physician saying that it was "unfair" for APRNs to be able to practice independently with less education than physicians. A psychiatrist suggested that the proposal is just another of the VA's "shady practices," saying that it is "interesting that as hospitals and insurance companies are making my credentialing more stringent, nurses move ahead unhindered, once again. Nurses are well organized politically—much better than docs—and have pushed their agenda forward. It does not mean they know medicine, just politics."

Predictably, however, most APRNs support the proposal as an improvement in the care of our veterans. A DNP said, "The VA's plan to serve our veterans using a very proficient and qualified provider (APRN) is a wise move. We need to create a significant change in how our service men and women are cared for after tours of duty. Tell the AMA to move over."

Outcomes, Dire or Otherwise

Physicians who commented on Medscape predicted mostly negative consequences from the VA's proposal for independent APRN practice, including lower standards of care and increased mortality for patients.

A concern, voiced by both sides of the debate, was that increased use of APRNs would result in excessive and unnecessary referrals. An RN feared that "NPs will allow patients to be seen quicker, only to send them to a specialist."

With strong differences of opinion on the quality of care provided by APRNs, many commenters turned to the evidence to bolster their opinions. Many APRNs reminded physicians that the research does not support their claims of inferior care by APRNs. "Forty years of studies support the assertion of safe, effective, cost-efficient care by NPs," said one NP. Physicians, however, do not accept the evidence, claiming that the studies were flawed.

"But why do we have to continually justify our skills?" asked another APRN. "In every profession there are bad eggs. Let us care for those we are able to, and when it is beyond our scope, there will be highly trained physicians to meet the needs of our patients. Medical care is going to suffer if we keep bickering about who's better than whom. We each play a vital role, and respect will only serve to improve our patients' outcomes."

The idea of banding together, rather than tearing each other apart, was espoused by several APRNs, and an argument was made to stop the quarreling and get on the same side of what really matters. "We are all getting taken apart and turned into protocol nonautonomous factory healthcare provider robots and box clickers. We are all losing pay, benefits, and control over patient outcomes, with more responsibility, more risk to our licenses, and more work, while hospitals and their executives get obscene salaries and bonuses," said an APRN. "We need to stop counting each other's training hours and start pushing back! Physicians need to start supporting and empowering NPs so that we can take healthcare back and physicians can regain control of their profession. We don't want your jobs, we just want to do ours."

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