Doctors rip VA plan that would give some nurses more authority

  1. A proposed rule by the Department of Veterans Affairs, which would dramatically expand the authority of nurses to treat patients without a doctor's supervision, is drawing attention to a bitter debate over the relative roles of doctors and nurses. This plan would give broad “new authority to its most trained nurses to order and read diagnostic tests, administer anesthesia, prescribe medications and manage acute and chronic diseases — without a doctor's oversight”.

    The agency says it is acting to meet a growing demand for care from veterans, both from the Vietnam era and the wars in Iraq and Afghanistan, amid a shortage of physicians on its staff. These nurses, who have advanced degrees, could practice independently even in the 19 states that still restrict what they can do, as long as they work for VA.
    But while groups that represent nurses praised the plan, it came under immediate fire from some of the country's largest doctors' groups, which said VA would be lowering the standard of care for veterans. Nurses lack training and skills to administer anesthesia and diagnose complicated illnesses by themselves, opponents said, particularly in a population with a vast array of medical issues.
    The president of the AMA was quoted as saying "All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine."

    The American Society of Anesthesiologists, which plans to hold a press conference Wednesday to denounce the VA plan, states "removing anesthesiologists from surgery and replacing them with nurses" would be "lowering the standard of care and jeopardizing Veterans' lives."

    What are your thoughts about this proposal and the opposing viewpoints?

    For more on this story read, Doctors rip VA plan to give some nurses more authority
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  2. 20 Comments

  3. by   quazar
    I admit, it worries me, at first glance. I also admit to not having read it in depth, because I have been actively avoiding the topic due to the fact that I have close friends and family members who are currently pursuing APN degrees, and I don't want to offend them with my opinions.

    Part of the reason I have concerns stems from experience with working with some APN nurses who really and truly did not practice safely, and honest to God NEEDED to have that physician supervision to rein them in and make sure they didn't do really bad/unsafe things. The worst part about working with those types of practitioners is that often they don't recognize their own ignorance, and say things like, "I know just as much as the doctors." Um, no. No, you don't. Unless you went to medical school and went through residency, no, you really don't.

    Yes, of course there are dangerous physicians, and I've worked with those as well. However, at least with an APN who has physician oversight, there is some mitigation of that problem, when it arises. This just seems to me to be a recipe for disaster. Maybe I'm wrong, and I admit my view is skewed. Who knows.
  4. by   CraigB-RN
    From the CRNA perspective, they have been practicing on their own around the country for years. You go to rural America and it's going to be a CRNA that does your anesthesia. The model chosen for CRNA schools has been well validated with them doing a full year of full time anesthesia. Not just 700 hours part time. When those veterans were soldiers, and needed surgery it was mostly likely a CRNA that did their surgery, sometimes in a forward operating theater.

    The Anesthesiologist have lost every battle in the country over this and this is pretty much their last stand over the subject. I haven't been able to find any documentation that supports the MD's stand. There may be some that I haven't found, but there is plenty of support for them being allowed to operate on their own.

    Now I'm not really sure where is coming from. In the bigger facilities there will still be an MD around. I can't see the medical centers not having at least one MD on staff.
  5. by   calivianya
    I have mixed feelings about APNs. I fully believe CRNAs are capable of being independent providers, as their training is so detailed and specific. NPs? Not so much. I believe NPs can do fine in primary care, but should have at least one supervising physician if they are going to be on a hospital-based service, be it a hospitalist or specialist group.

    I recently had a NP remain unconvinced that a patient with a history of multiple CABG surgeries, a-fib, heart failure, and one replaced valve and two other diseased valves was experiencing a heart problem when he had been in a-fib with RVR with a HR of 140-180 since his admission and I was attempting to get it fixed. I had to give a fluid bolus (to a known CKD/HF patient) and get a chest X-ray and an ABG before I could finally convince her to give me something for rate control, despite repeated mentions that he was taking a beta blocker at home which he did not currently have ordered. I have these sorts of experiences where I end up beating around the bush, giving unnecessary treatments, and calling much more often because the previous "fix" did not work with NPs more frequently than with MDs. I am just not convinced that they are able to manage complicated patients independently.
  6. by   CraigB-RN
    I had a new grad NP ask me why I wanted a sliding scale for my diabetic patient when they were NPO.

    There are a lot of factors that come into play. One of those factors is that we tend to remember the bad in detail and the good not so much which is why anecdotal accounts aren't really useful. I've worked with many NP's who I'd let take care of me anytime. I know a few who are actively responsible for pushing the envelope on new medical knowledge.
  7. by   KatieMI
    The plan failed simply because it was about too many things changing too much, and at once.

    There were times, not more than some 30 years ago, when nurses were not supposed to know anything at all beyond the basics and how every doctor in the unit wanted his coffee to be served. I still see old-schoolers who refuse to believe that nurses do know a few things, and some nurses know quite a lot. Plus, thete are areas no many doctors know much about, anesthesiology among them.

    If VA would start from "nursing driven protocols" for a few common conditions to begin with, it would be much more accepted. An RN can be trained with three or four weekend classes to apply Framingham and initiate preventive screen/statin/HTN treatment, with follow-up with a specialist for the highest risk patients or anything which doesn't fit. It will sure miss most secondary hypertensions and other zebras, but horses will be mostly caught and herded out. In a few years, when everybody get used to that, next protocol could be developed and introduced.

    Just please, no weekend training for anesthesia.... of any kind. Get more CRNAs.
  8. by   quazar
    Props to the PP for a well-used House of God reference.
  9. by   Cook26
    The statement was made by the ASA to stifle CRNA independence. Nurses have been administering anesthesia for over 100 years.

    I am an anesthesia student currently. I will graduate with more than 4000 practice hours.

    Today I was in the OR at 5am until 4pm, had class for 4 hours and just got home to study and make plans for my cases tomorrow.
  10. by   Psychcns
    There are good and bad NP's and good and bad MD's. I have had some very good physician supervisors and others who do not want to teach or supervise. I always seek collaboration when I have questions but I find if I think about a problem long enough and research it I will find a solution. Mandatory supervision can be an obstacle to providing care.
  11. by   elkpark
    Quote from KatieMI
    There were times, not more than some 30 years ago, when nurses were not supposed to know anything at all beyond the basics and how every doctor in the unit wanted his coffee to be served.
    I was in nursing school and then practicing more than 30 years ago, and I can tell you that my experience of nursing education and practice at the time was nothing at all like your characterization. I have taught in ADN and BSN programs since then, and I can assure you that the students in my hospital-based diploma school graduated knowing significantly more about nursing, and better prepared to practice nursing, than most nursing students have been in recent years. Nurses were competent, knowledgeable, respected professionals. We weren't serving any coffee to physicians.
  12. by   dudette10
    If NP education was as rigorous as CRNA education, no problem. Yes, there are good and bad MDs and there are good and bad NPs; however, I think the percentage of bad NPs far exceeds bad MDs when first starting out. The application requirements, th education, and the training prior to full scope of practice must be much more rigorous than it is now. If anything, all theses things are LESS rigorous then they were 10 years ago.

    A dozen of my coworkers are going to NP school. I know many more of my nurse friends and school mates who are going. Medicine is a bit more than treating by algorithm, which seems to be the thing to do among newer NPs, as if that protects them from malpractice and wrong choices. I heard the newer acute care NP talking to her supervising physician about her recommendation for an minimally invasive procedure. The physician said, "No! Why would you do that!?" The NP answered, "That's what UpToDate said!"

    As many have opined, there will be a glut of NPs in a few years. Once independent practice NPs start getting sued for malpractice, we'll see a change in the education requirements. It's sad that it will have to come to that.
    Last edit by dudette10 on Jun 6, '16
  13. by   Lisa.fnp
    Quote from dudette10
    If NP education was as rigorous as CRNA education, no problem. Yes, there are good and bad MDs and there are good and bad NPs; however, I think the percentage of bad NPs far exceeds bad MDs when first starting out. The application requirements, th education, and the training prior to full scope of practice must be much more rigorous than it is now. If anything, all theses things are LESS rigorous then they were 10 years ago.

    A dozen of my coworkers are going to NP school. I know many more of my nurse friends and school mates who are going. Medicine is a bit more than treating by algorithm, which seems to be the thing to do among newer NPs, as if that protects them from malpractice and wrong choices. I heard the newer acute care NP talking to her supervising physician about her recommendation for an minimally invasive procedure. The physician said, "No! Why would you do that!?" The NP answered, "That's what UpToDate said!"

    As many have opined, there will be a glut of NPs in a few years. Once independent practice NPs start getting sued for malpractice, we'll see a change in the education requirements. It's sad that it will have to come to that.
    Thanks for sharing personal opinion and feelings. If only scientific case studies supported it.

    As for sharing communication between a Physician and Nurse Practitioner, in which the reply from the NP was. 'That's what UpToDate said!'
    Do you have a membership to UpToDate? I do, and I would refer to UpToDate over anyone's opinion. For UpToDate is a is unlike any other clinical resource:
    It's more comprehensive than any other individual resource, UpToDate contains the equivalent of over 77,000 pages of original, peer-reviewed text.
    Its unique format and search capability allow you to access answers to clinical questions quickly and easily. You get the answer you need when you need it.
    It is written, reviewed and continuously updated by over 5,100 physicians to ensure that the content remains current.
    This expert faculty synthesizes all relevant information, including the latest evidence, and provides specific, practical recommendations for diagnosis and treatment.
    It combines broad coverage of adult primary care, subspecialty internal medicine, ob/gyn, general surgery and pediatrics. UpToDate performs a continuous comprehensive review of more than 460 journals to keep the program updated.
    This NP should be praise for paying the hundreds of dollars a year to have access to such a wonderful resource not knocked down by you for standing up to a Physician.
  14. by   RiskManager
    I am certainly in support of the VA's plan to increase NP autonomy. I reside in a state in which NP's are independently licensed providers. However, we should not forget that regardless if the provider is a physician, NP, CRNA, CNM, PA, podiatrist, or another type of licensed independent provider; the VA, or for that manner any large(r) healthcare employer or system will still have a mechanism of supervision and peer review for those providers. I think it is a misnomer to state that any provider, outside of a small independent practice with no hospital privileges, practices without supervision. From my perspective of enterprise risk management to safeguard patient safety, the providers/staff and the liability and regulatory interests of the organization, every provider will be appropriately supervised and peer-reviewed. The sticky wicket come in when people are alleging that the supervision and peer review is driven by financial and turf issues, not clinical or evidence-based practice.

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