From his Fresno, California, office, Dr. Andrew Wall has joined what’s fast become a national fight over the powers granted to Department of Veterans Affairs nurses.
Citing potential physician shortages, the department wants to expand its nurses’ roles in advanced care. The proposal has split the medical community, drawn congressional attention and prompted more than 11,700 public comments as of Friday afternoon, making it the hottest topic in the federal regulatory world.
A number of doctors oppose the VA’s idea.
“Many veterans have multiple other medical conditions that potentially complicate their anesthesia,” Wall wrote in a public comment posted May 26. “Having a physician with medical, as opposed to nursing, training involved in their care makes this the safest possible care.”
In an interview Friday, Wall noted that he was, himself, a nurse before becoming a doctor, and he acknowledged that “there are some strong feelings on both sides.”
Dr. Stephen G. Mlawsky, based in Mill Valley, north of San Francisco, said in his own written comment Wednesday, with uppercase emphasis, that “the level of care will NOT be comparable to physician encounters with patients.”
Allowing full nursing practice authority is often raised as a key approach to addressing national physician workforce shortages and access problems, particularly in primary care.
Department of Veterans Affairs
Phillip Grenier, president of the California Association of Colleges of Nursing, countered that “these changes should help alleviate the long wait times at VA facilities by providing additional qualified care providers,” and nurses have been mobilizing in support of the VA.
“This is a way of providing high quality, cost-effective health care,” Marla J. Weston, president of the American Nurses Association, said in an interview Friday, adding that “Veterans Affairs has been looking at this idea for about seven to nine years.”
In its proposal, the VA sought to give “full practice authority” for registered nurses to provide advanced nursing services without the clinical oversight of physicians. Advanced nursing services can include anesthesia and midwifery.
“The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future,” VA Undersecretary for Health Dr. David J. Shulkin said in a statement.
Twenty-one states, including Idaho and Washington, have already expanded nurses’ scope of practice, empowering them to manage treatments, diagnose patients and more. The VA said doing the same at veterans’ hospitals “would increase VA’s capacity to provide timely, efficient and effective primary care services, as well as other services.”
The proposal sets certain training requirements for the advanced-practice registered nurses, and would exempt them from scope-of-practice limits imposed in states including California, Texas, Florida, Missouri and the Carolinas. Put another way, Weston said, the proposal “would basically standardize” the rules governing VA advanced nursing practices.
All sides bring political muscle to this brawl.
The American Society of Anesthesiologists Political Action Committee contributed $1.4 million to federal candidates during the 2014 election cycle and should at least match that this cycle, records show. The 180,000-member American Nurses Association, which declares on its website that “when nurses talk, Washington listens,” contributed $353,000 to candidates last cycle.
The anesthesiologists’ association also spent $1.2 million on lobbying last year, as did the nurses’ association. Other medical associations have weighed in, as well. Common persuasion tactics include encouraging members to send form letters, such as those from both sides now flooding the VA for a public comment period that ends July 25.
Eleven members of Congress, all medical professionals before entering politics, have urged the VA to back off, as have other medical professionals.
“Patients in the VA hospital system are some of the the sickest patients I have seen,” wrote Dr. Tiffany Doan, a medical resident at Baylor College of Medicine in Texas, adding that “this proposal to allow ‘advanced’ nurse practitioners to care for our veterans without the supervision of a medical doctor baffles me.”