Certified Registered Nurse Anesthetists Support
January 13th, 2017
The Honorable Robert A. McDonald
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Washington, DC 20420
Director, Regulations Management (02REG)
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Room 1068
Washington, DC 20420
RE: RIN 2900-AP44- Advanced Practice Registered Nurses (81 Fed. Reg. December 14, 2016)
Dear Secretary McDonald,
On behalf of the 52 undersigned national professional nursing organizations representing the Nursing Community coalition, we write to share our appreciation and urge continued action for the final rule published by the U.S. Department of Veterans Affairs (VA) on December 14, 2016 (Federal Register Document Number 2016-12338, RIN 2900-AP44)i regarding Advanced Practice Registered Nurses’ (APRNs) clinical practice within the Veterans Health Administration’s (VHA).
As a coalition, our associations have advocated for APRNs (including Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Certified Nurse-Midwives (CNMs), and Clinical Nurse Specialists (CNSs)) in the VHA to practice to the full extent of their education and training since 2013. We applaud the ruling that rightfully grants veterans direct access to three of the four roles (NPs, CNMs, and CNSs), but urge the department to include CRNAs as part of its full implementation.
Collectively, the Nursing Community represents over one million registered nurses, APRNs, nursing faculty, students, researchers, and nurse executives. Our associations advocate on a wide variety of issues to advance health and healthcare through the nursing profession. This rule supports our principal mission to promote America’s health through nursing care and will directly impact the practice of over 6,000 APRNs who have dedicated their lives work to treating veterans and their families.
Health care in our country continues to progress toward patient-centered models of care where providers and appropriate coordinated services develop an individualized care plan to meet patients’ needs. This rule helps achieve this endeavor by allowing the VHA to manage its resources more prudently and fully employ the skills of healthcare providers to the full extent of their education, training, and certification. Removing additional burdensome requirements of “clinical supervision from physicians,”i (p. 90199) as the rule states, ensures the focus on the primary mission of the VHA which is “provide a complete medical and hospital service for the medical care and treatment of veterans” i (p.90199 ). We firmly believe that this goal cannot be achieved if CRNAs are not included in the final rule.
CRNAs Support Veterans’ Access to Care
The rule details that VHA sites will have the opportunity to expand access to care by removing barriers to APRN practice. We concur that this will be of utmost importance in sites that struggle with provider recruitment and retention in medically-underserved communities. Yet, the rationale the VA cited in the final rule for not including CRNAs was “lack of access issues in the area of anesthesiology”i (p. 90199). The rule acknowledged that there are “difficulties in hiring and retaining anesthesia providers but generally believes this situation is improving” (p. 90200).
We find three grave inconsistencies with this approach.
First, a Health Affairs article highlighted the fact that “37,000 certified registered nurse anesthetists provide thirty million anesthetics annually in the United States and represent twothirds of anesthetists in rural hospitals”ii(p.1469). As the VHA looks to ensure services reach its nation’s veterans in rural and underserved communities, CRNAs are a critical link to providing that care.
Second, the rationale that the hiring and retention of anesthesia providers is “generally improving” is a shortsighted approach to crafting national policy. Healthcare trends and the needs of our nation’s veterans are not static. To base a rule on the present, without regard for the future, will only harm the population this rule was intended to support— America’s veterans.
Third, according to a recent article, the VA has stated that about half of older veterans and about 60 percent of veterans returning from deployment suffer from chronic pain.iii Moreover, the number of veterans with opioid use disorders has increased 55 percent from 2010 to 2015.
CRNAs are doing their part to address the national opioid crisis with a holistic approach to pain management. CRNAs are trained and qualified to provide a holistic multimodal approach to chronic pain management, including interventional pain management, to help meet veterans’ need for this service.
Finally, the VA’s rulemaking utilized the Federal preemption clause on state nursing licensure which enables standardization of APRN practice to the full extent of their education and training. This streamlined approach should be inclusive of all four APRN roles to fully realize the standardization and consistency that the VHA is expecting with the implementation of this final rule. The standardization will allow for more efficient use of APRN staff in the VHA by increasing capacity for timelier, safe, efficient, and effective delivery of care services.
The successful execution of this rule should require that all providers in the VHA−including CRNAs— are utilized to the full extent of their education and training. Again, we respectfully urge the VHA to include CRNAs in future implementation of this rule. If you have any questions, please contact the Convener of the Nursing Community, Dr. Suzanne Miyamoto, at Smiyamoto@aacn.nche.edu.
Sincerely,
Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Assembly for Men in Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Association of Nurse Practitioners
American Association of Occupational Health Nurses
American College of Nurse-Midwives
American Nephrology Nurses Association
American Nurses Association
American Nursing Informatics Association
American Organization of Nurse Executives
American Public Health Association, Public Health Nursing Section
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Rehabilitative Nurses
Association of Veterans Affairs Nurse Anesthetists
Commissioned Officers Association of the U.S. Public Health
Dermatology Nurses’ Association
Developmental Disabilities Nurses Association
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society
International Society of Psychiatric-Mental Health Nurses
National Association of Clinical Nurse Specialists
National Association of Nurse Practitioners in Women’s Health
National Association of Pediatric Nurse Practitioners
National Black Nurses Association
National Council of State Boards of Nursing
National Forum of State Nursing Workforce Centers
National Gerontological Nursing Association
National League for Nursing
National Nurse-Led Care Consortium
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Organization for Associate Degree Nursing
Pediatric Endocrinology Nursing Society
Preventative Cardiovascular Nurses Association
Society of Pediatric Nurses
Society of Urologic Nurses and Associates
The Quad Council of Public Health Nursing Organizations
Wound, Ostomy and Continence Nurses Society
Cc:
David J. Shulkin, MD
Under Secretary for Health, VA
Linda M. McConnell, MSN, RN, NEA-BC, FACHE
Chief Nursing Officer
Office of Nursing Services, VA
i Federal Register. (2016, December 14). Advanced practice registered nurses. Retrieved December 15, 2016, from https://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses
iiDulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29,1469-1475.Rtrieved from: http://content.healthaffairs.org/content/29/8/1469.full.pdf+html?ijkey=ezh7UYKLtCyLY&keytype=ref&siteid=heal
thaff.
iii Reporter, S. D., & Group, F. E. J. (2016, March 28). Veterans face greater risks amid Opioid crisis. Retrieved January
6, 2017, from http://www.pbs.org/wgbh/frontline/article/veterans-face-greater-risks-amid-opioid-crisis/