Physician Practice

VA expands scope of practice for most APRNs

Physician Practice Insider, December 27, 2016

Advanced practice registered nurses (APRN) who work for the Department of Veterans Affairs (VA) will have full practice authority effective January 13, 2017, according to a final rule published December 14. Certified registered nurse anesthetists (CRNA) will not have their scope of practice expanded under the final rule, although the VA is accepting comments on this and may consider expanding the scope of practice of CRNAs in future rulemaking. Comments are due January 13, 2017.
The rule describes three categories of APRNs and the scope of full practice authority for each type. These APRNs will be able to provide services to the full extent of their training and licensure without mandatory clinical supervision of a physician.

The rule also outlines professional qualifications an APRN must possess and creates criteria for the VA to grant full practice authority. The three types of APRNs are:

  • Certified nurse practitioner
  • Clinical nurse specialist
  • Certified nurse-midwife

The scope of practice permitted to APRNs varies widely from state to state, and this patchwork of regulations makes it difficult for the VA to establish standardized practice among its facilities and ensure adequate staffing. Veterans seeking care through the Veterans Health Administration often face long wait times and difficulties accessing care due to a shortage of physicians, according to a U.S. Government Accountability Office report released in April. Expanding the scope of practice permitted to APRNs is one of the VA’s strategies for reducing wait times and improving care for veterans.

Physician groups were critical of the proposed rule and, in a December 15 statement on the final rule, the American Academy of Family Physicians called the final rule a quick fix that will undermine patient safety.

Groups representing APRNs counter that the final rule will lead to better outcomes for veterans. The American Association of Nurse Practitioners praised the final rule but added that it hopes CRNAs will be granted full practice authority in the near future.

The American Association of Nurse Anesthetists (AANA) expressed disappointment that CRNAs were not included. The AANA pointed to support from veterans and their families, and veteran advocacy groups, for expanding the practice authority of CRNAs. A study published in in the October issue of Medical Care shows no measurable difference in anesthesia-related complications between patients treated by physician anesthesiologists or by CRNAs operating independently of physician supervision. CRNAs in the military practice without physician supervision in combat zones, and the AANA repeatedly pointed to this policy discrepancy in statements.

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