Reassuring the VHA, Healthcare Consumers, & 60 Physician Groups about Advanced Practice Registered Nurses Providing Safe, Quality Care to Veterans

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Not too long ago, I wrote a post about 40 professional nursing groups who were supporting the Veterans Health Affairs (VHA) plan to update it’s nursing handbook and empower Advanced Practice Registered Nurses to provide care under their own licensure rather than have oversight by physicians.  This is part of a bigger picture involving one of the Institute of Medicine’s recommendations from their report on the Future of Nursing which essentially sought to create safe, quality healthcare for all USA citizens.  In reality, APRNs are qualified to provide a much-needed level of healthcare at a cheaper rate without sacrificing safety or quality.

Did you know that currently over 6,000 APRNs provide a full range of services for our 120px-No_medical_adviceVeterans in the VHA?  The safety of APRN services has long been recognized by the VHA and underscored by peer-reviewed scientific studies.  These studies have proven consistently that the care provided by APRNs, practicing to their full scope of practice, is equal to the care of their physician counterparts.  This large and ever growing body of evidence has led the Institute of Medicine, AARP, the Robert Wood Johnson Foundation, the Josiah Macey Foundation, the National Governor’s Association and the Federal Trade Commission to endorse recognizing APRNs to their full scope of practice.

Not long after I published the post, I received a copy of a letter sent to Robert Petzel, MD Undersecretary for Health Department of Veteran Affairs.  The letter opposes the VHA’s plan to empower APRNs and is signed by 60 physician groups. It is despairing to see all of these powerful physicians align against an effort that is designed to provide safe, quality, and cost-effective care to Veterans.  (email me if you’d like a copy of the letter:

The letter expresses concerns that APRN’s practicing independently will undermine the delivery of care within the VHA and that it will interfere with physician leadership of teams, and that the approach will further fragment care.

BB closer Headshot 1-13 CherationsHonestly, I don’t get it. 

I’ve been an RN for over 25 years and have a pretty good sense of what is involved in the education of APRNs, their safety record, and scope of practice among the various specialties. I would not hesitate to have an APRN as my primary care provider or to have one caring for my mother or son.

APRNs will engage MDs, DOs, or other healthcare professionals when necessary just as MDs engage specialists. This way, the cost of more specialized care would be incurred only when it is warranted.  Certainly, a primary care physician (PCP) does not need to be supervised by a neurologist for treatment of neurologically related problems that the PCP feels capable of handling.  Even though a neurologist has had more education than the primary care doctor about such problems.  When the neurologist is needed the PCP makes a referral and depending on clinical issues, patient and primary care provider, and reimbursement plans this specialist will become part of the patient’s healthcare team and at times play a leadership role. Isn’t that feasible with doctors and APRNs under the new VHA nursing handbook?

In a related Wall Street Journal Article about the topic by Melinda Beck, the American Society of Anesthesiologists warned that allowing nurse anesthetists to work independently could decrease quality of care at the VHA, where patients are typically in poorer health than the general population. The group says physician anesthesiologists are far better prepared to address emergencies, and it notes that a 2000 study in the journal Anesthesiology found mortality rates are higher for patients who undergo surgery without a physician anesthesiologist.

Beck’s article goes on to point out that the American Association of Nurse Anesthetists cite a “2010 study in Health Affairs that found no difference in patient outcomes whether anesthesia was administered by a physician or a nurse anesthetist, with or without supervision.”  And further reports that “physician anesthesiologists ranked sixth in average income among medical specialists in 2013, according to Medscape’s annual physician-compensation report. Nurse anesthetists typically make far less than their physician counterparts, their association says. In some surgical settings, anesthesiologists supervise as many as four nurse anesthetists at a time and collect 50% of their fees.”

Do you think we need physician oversight for APRNs? Should specialty physicians supervise primary care doctors? Can APRNs lead healthcare teams?  Do you have experiences with APRNs?


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15 Responses to Reassuring the VHA, Healthcare Consumers, & 60 Physician Groups about Advanced Practice Registered Nurses Providing Safe, Quality Care to Veterans

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  12. Dean Smith says:

    Beth, as a former Independent Duty Corpsman, I can attest that most APRN’s provide the first level of Primary Care far more effectively than physicians. I did a similar role while in the military because the MD’s on the front line often were based more strategically. Likewise the VA will be taking the “wave” with the reduction of force in the coming year. Unlike post – the previous conflicts, we have more veterans coming back that will require care. This makes sense as the MD’s have more or less abandoned the primary care role within the VA structure. Someone has to do the job. I agree that the MD’s are now realizing with meaningful use of what they have “given away”. hopefully, the VA will see through those “60 physician” organizations ruse and go ahead with their plans to expand the roles of APRNs, I know the returning veterans will be better served. Cheers Dean

  13. Thanks, Lisa! Excellent points about education and holistic approach of APRNs. The ideals around patient-centered care are consistent with nursing education, training, and experience and have been long before this term became popular.

  14. Lisa Burden says:

    Since APRNs have masters degrees with the practicum aspect afterward. the educational level is as superior as physicians. The level of care I feel is better since nursing practice focuses on all aspects of the patient whereas medicine usually targets the treatment of the symptoms that a patient presents. I know that I personally have been treated by both and have received more “care” from the APRN than the MD.

What are your thoughts?