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This Battle over Advanced Nurses Feels Familiar to Me


The VA's recent proposal to expand the scope of practice for advanced practice registered nurses has sparked a debate that's been brewing for a while.

Welcometo Editor's Corner. Here, the editors of Physicians Practice will share their thoughts on the happenings in healthcare and look at the industry from a broader viewpoint.


The waitlist debacle will likely go down as one of the biggest black eyes in the history of the Veterans Health Administration (VHA).

In case you were under a rock during the spring of 2014, a Veterans Affairs internal investigation revealed that more than 1,000 veterans had waited months to see a doctor to receive care at the Phoenix VHA facility. Of the 1,000-plus veterans, at least 40 had died while on the waiting list, CNN reported at the time. The number was later revised to 35, but the CNN report turned this issue into a full-blown scandal. You couldn't flip on cable news channels without someone weighing in about the VHA's failure to care for veterans.

It was later revealed through an internal audit, the problem extended well beyond Phoenix. The revised number of veterans across the country who experienced long waits to receive care was more than 120,000. The scandal caused top officials, Eric Shinseki, the Secretary of Veterans Affairs, and Robert Petzel, a physician and the Undersecretary of Health for the VA, to resign.

Fast forward two years and it appears the VA's waitlist problem has not gone away. The issue still persists and current VA secretary Robert McDonald's recent remark that healthcare wait times for veterans could be compared to people waiting online at Disneyworld didn't do the agency any favors. Rep. Paul Ryan, Speaker of the House, said McDonald's remarks indicated a "culture of indifference" at VHA.

About one day after this latest snafu, the VHA announced a proposal that aims to quiet its doubters and fix the issue, once and for all. The proposal would expand the scope of practice for advanced practice registered nurses (APRNs), giving them full practice authority when they are acting within the scope of their VA employment.

Seeing as the VA is the country's largest health system, this move could have major ramifications. Already, 21 states and Washington D.C. have given nurse practitioners, whom are included in VHA's APRN designation, full practice authority. If this proposal goes through, it could motivate APRNs in states where they don't have full practice authority to push for it.

Of course, the move from the VA warranted different types of response from advocacy groups representing nurses and doctors. The nation's largest doctor group, the AMA went on the attack: "While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans."

The American Association of Nurse Practitioners (AANP), on the other hand, applauded the move: "Veterans stand to significantly benefit from this essential VA policy update, which gives them unencumbered access to nurse practitioners and the excellent, compassionate, and patient-centered care they provide," said AANP President Cindy Cooke in a statement.

For yours truly, this "battle" feels familiar. A few weeks ago, I posted my feature story, The Uncertain Role of NPs and PAs in Today's Practice. The article was essentially about this very debate: With a doctor shortage looming, should NPs and physician assistants (PAs) be given more authority in a practice?

Like with the VHA proposal, I got mixed responses from doctors and nurses. Many doctors worry that NPs are not interchangeable with MDs and giving them full authority would water down patient care. NPs and doctors who advocate for advanced practitioners say they provide a role that will help with the provider shortage, but only if they are given more authority. The back-and-forth actually spilled into the online comment section:

"I think if the PAs and ARNPs want to have all the privileges and freedom to practice like physicians, all they have to do is go to the medical school," one commentator wrote. "And if they did go to medical school? What would you say then? Because most PAs did attend a medical school as I did," another responded.

The VHA, for its part, wants to hire more doctors (3,800 to be exact). However, like everyone else, they are having a hard time finding MDs to bring aboard.

Whether or not this proposal will help solve their problems is up for debate. It's hard to say who is right, the AMAs of the world or the AANPs. I do feel more data would help us determine the roles each practitioner should play in a patient's care plan.

What's easier to predict is that the VHA proposal to extend practice autonomy for APRNs will be a watershed moment in this discussion. What happens here may very well shape future policy governing the scope of practice for advanced practitioners.

Follow Gabriel Perna on Twitter at @GabrielSPerna

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