The Veterans Health Administration has weighed in on a controversy that has embroiled medicine and nursing for the last 50 years: whether advanced practice registered nurses (APRNs) can operate without direct physician supervision. On December 14, the VHA amended its medical regulations to "permit full practice authority" to many of the system's nurse practitioners, a move that immediately drew the ire of the medical community.
Since APRNs appeared on the health-care stage in 1965 with the enactment of Medicare and Medicaid, physicians have responded with deep ambivalence. Some have embraced them as full members of the health-care team, while others-particularly leaders of organizations like the American Medical Association-have argued that nurses should not function on their own and should always-no matter how much experience they have-work under the direction of doctors. APRNs have consistently argued that they should be allowed to make diagnoses and prescribe treatments without physician supervision.
The Institute of Medicine has recommended APRNs be granted what is known as "full practice authority," and countless studies have documented that APRNs provide safe and effective care at lower costs than physicians. The fight has been waged in various states, 22 of which have granted full scope of practice to APRNs. But as a federal employer, the VHA's own internal regulations can supersede state law on nursing practice when there is conflict between state law and federal law. The VHA's new ruling, which will establish additional "professional qualifications an individual must possess to be appointed as an APRN within the VA," might actually lead to requirements stricter than those of some states.
This is by no means an arcane, internecine fight. Advanced-practice nursing appeared in the 1960s because of the need to expand health-care access in a country that did not, and still does not, produce enough generalist physicians but overproduces medical specialists. Over the years, nurse practitioners and other APRNs have become increasingly critical in both pediatric and adult primary care, as well as in specialist clinics and acute-care settings where they work on medical teams.
Of the 93,500 registered nurses, licensed practical nurses, and nursing assistants employed by the VHA, more than 5,700 are advanced practical nurses (APRNs), hired to work on primary-care teams or in settings with provider shortages. In its deliberations on the future of the VHA, for example, the VA Commission on Care recommended that APRNs be allowed to practice to the full extent of their education, training, and certification, which means without direct physician supervision.
When the VHA's regulation came out, medical leaders expressed their usual reservations about APRN practice. During the 60-day comment period for the proposed ruling, just the hint of liberating APRN practice unleashed an unprecedented torrent of comments from the American public (including many veterans and their families) and professional organizations. AMA President Andrew Gurman immediately denounced it, saying, "We are disappointed by the VA's decision today to allow most advanced practice nurses within the VA to practice independently of a physician's clinical oversight, regardless of individual state law."
Medical leaders must stop defending an outdated model in which physicians, some of whom may have no training in either leadership or teamwork, dominate the health-care team. It is time to follow the lead of the VHA and establish a model of care that helps not just veterans, but all Americans.
