David Shulkin, undersecretary of health for the Department of Veterans Affairs, with VA Secretary Bob McDonald at a House hearing in February, 2016.

David Shulkin, undersecretary of health for the Department of Veterans Affairs, with VA Secretary Bob McDonald at a House hearing in February, 2016. (Joe Gromelski/Stars and Stripes)

WASHINGTON — To address staffing shortages across the country, the Department of Veterans Affairs will allow thousands of advanced practice nurses nationwide to treat patients without physician supervision.

Starting Jan. 13, certified nurse practitioners, clinical nurse specialists and certified nurse-midwives at VA hospitals will be authorized to “practice to the full extent of their education … without the clinical supervision or mandatory collaboration of physicians,” the rule states.

David Shulkin, the VA Undersecretary for Health, said the change would free up physicians, alleviating challenges the VA has with getting veterans quick access to medical treatment. But the physician-led American Medical Association said the rule would do away with the team-based care that’s been adopted at the VA and revert it back to an “outdated model” of health care delivery.

The VA started a system-wide effort to hire additional health care providers and speed up veterans’ access to treatment in 2014, when media reports and internal investigations revealed veterans had long waits for care and managers were manipulating wait-time data.

Approximately 93,500 nurses are on the payroll at the VA, making it the county’s largest employer of nurses. About 5,700 of them are advanced practice, meaning they have a master’s or doctoral degree in a nursing specialty.

To meet veterans’ needs, the VA has estimated it needs to hire 40,000 more nurses by 2018.

Last year, the Government Accountability Office issued a report stating it was especially hard for the VA to recruit and retain nurses with advanced training.

The rule falls in line with a recommendation from the Commission on Care this fall that called on the VA to more effectively use the health care providers it already has.

The Commission on Care was established by Congress to make recommendations on VA reform, and its duties concluded earlier this year when it released its final report. In the report, commissioners wrote the VA was “failing to optimize use of advanced practice nurses.”

“In the Navy, we would never train a sailor to use 10 skills and then limit them to three; it makes no sense,” retired Capt. Kathryn Beasley, with the Military Officers Association of America, said at a press conference about the rule earlier this year. “No one would do that. But that’s what illogical and wasteful practice limitations on highly skilled advanced practice nurses do.”

State laws determine what advanced practice nurses are allowed to do. Nurses at VA hospitals in 22 states already have full-practice authority because their states allow them to evaluate, diagnose and treat patients and prescribe medications.

Some states require advanced practice nurses to be supervised while treating, diagnosing and prescribing patients. Others allow APNs to treat and diagnose patients alone but require oversight for prescribing medications.

“For example, the same nurse practitioner is required to have more physician oversight in Kansas City, Mo., than across the state line in Kansas City, Kan.,” the American Nurses Association wrote in a statement.

Under the VA’s new rule, advanced practice nurses will be exempted from state laws that restrict their practice.

Members of groups such as the American Association of Nurse Practitioners and the ANA reacted happily to the rule’s announcement, saying it’s something they’ve lobbied for over several years.

“This is a win for veterans, as well as the VA nurses who treat them,” the ANA wrote.

The rule change has pitted nurses groups against other groups advocating for physicians, which claim educational gaps make advanced practice nurses unqualified to serve as primary care providers.

After a proposal was posted on the Federal Register in May, it received more than 223,000 comments in two months. It garnered thousands more when the VA announced this month the rule was finalized. The VA will continue to accept comments until Jan. 13, when the change goes into effect.

The American Medical Association prompted questions of whether advanced practice nurses had enough training to treat patients without supervision.

The VA responded to those comments, saying advanced practice nurses would not be altogether replacing physicians or providing treatment beyond their training.

The AMA also argued the change would get away from the VA’s team-based approach to health care, in which a primary care provider, nurse and others work together to treat veterans.

“All patients deserve access to physician expertise,” AMA president Andrew Gurman said in a statement. “Providing coordinated, physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country’s veterans, especially given the highly complex medical care that veterans often require.”

The VA reiterated that it would not do away with its model of team-based care.

The rule giving APNs full-practice authority will go into effect Jan. 13. That’s also the last day the public can comment on the change. Twitter: @nikkiwentling

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Nikki Wentling has worked for Stars and Stripes since 2016. She reports from Congress, the White House, the Department of Veterans Affairs and throughout the country about issues affecting veterans, service members and their families. Wentling, a graduate of the University of Kansas, previously worked at the Lawrence Journal-World and Arkansas Democrat-Gazette. The National Coalition of Homeless Veterans awarded Stars and Stripes the Meritorious Service Award in 2020 for Wentling’s reporting on homeless veterans during the coronavirus pandemic. In 2018, she was named by the nonprofit HillVets as one of the 100 most influential people in regard to veterans policymaking.

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