The latest salvo in the federal government’s war on physicians comes to us courtesy of the Veterans Health Administration (VHA), which is proposing drastic policy changes to expand nursing scope of practice in all veterans’ hospitals.
A new draft VHA Nursing Handbook would eradicate all existing VHA policies concerning physician supervision, and would designate all advanced practice registered nurses (APRNs), including nurse anesthetists, as licensed independent practitioners (LIPs). This means that they would be able to practice on their own without any requirement for physician oversight or support. In 2011, the Office of General Counsel upheld the VA’s claim of the right to authorize APRNs to function as independent practitioners “regardless of the scope of practice defined by their licensure.”
And if a nurse practitioner or a nurse anesthetist would rather practice in a care team with a physician, that’s too bad. The new policy wouldn’t be optional. As the Office of Nursing Services bluntly (if ungrammatically) stated in an explanatory document, “If the APRN does not want to attain independent status they would not be able to practice as an APRN in the VHA.”
The new VA policy would supersede any state law or individual hospital policy requiring physician supervision or defining limitations to nursing scope of practice. ”A local policy that restricts APRN privileges is not appropriate,” the ONS document asserts, noting that APRNs are to function “at the top of their license” and that current medical staff bylaws in many VA hospitals “will most likely need to be revised.”
The long-standing VHA Anesthesia Service Handbook would be supplanted by the new rules. It supports team-based care combining the different skills of physicians and nurses, and specifies that “care needs to be approached in a team fashion taking into account the education, training, and licensure of all practitioners.” It also provides flexibility to individual VA Chiefs of Anesthesiology to set their own department’s policies. These concepts, apparently, are now out of favor.
The California Society of Anesthesiologists (CSA) and the American Society of Anesthesiologists (ASA) strongly oppose the new proposed policies. They note that patients in veterans’ hospitals are 14.7 times more likely to have poor health status than the general population, and 14 times more likely to have 5 or more medical problems, according to a study in JAMA Internal Medicine. Veterans are more likely to have complications during a surgical procedure, and they deserve physician-level expertise on their anesthesia care teams. CSA leaders Peter Sybert MD and Mark Zakowski MD were instrumental in obtaining the co-signatures of California Representatives Julia Brownley, Paul Cook, and Raul Ruiz MD on a letter to the Secretary of Veterans Affairs, urging the retention of the team care concept and the current policy directives in the VHA Anesthesia Service Handbook.
What can we do as individuals to speak up against the VHA’s proposed mandate for APRN independent practice? Contact our U.S. Representatives and Senators by phone or email. For anesthesiologists, the ASA Grassroots Network has drafted an email appropriate to send to lawmakers on the proposed VHA nursing policy changes, and will send it for you with your signature. Or call your senators and U.S. representative at their offices and speak to their healthcare legislative aides. The new policy handbook is nearing its final version, so timing is critical. Our veterans deserve better.
Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center. She blogs at A Penned Point.