There been a lot of heated and sometimes unprofessional discourse about the VA Advanced Practice Registered Nurses proposed rule (open for comments until July 25th) but not many folks have actually read the full rule language.  In my opinion, it contains nothing to provoke anger or disrespect.  There is nothing to take personally.  There are no insults to any professional groups’ abilities or intentions.  It is just a policy proposal, with which you may agree or disagree.  Many people have strong feelings on the policy, but there is no need for vitriol.

Let’s take a look:

anesthesiologists save lives


First, what is the scope of the proposal? “VA is proposing to exercise Federal preemption of State nursing licensure laws” meaning the rule would replace physician oversight “regardless of individual State restrictions that limit such full practice authority”.  Maybe I am a political nerd, but I personally find this an interesting  federalism issue – that is, a potential conflict of national vs state powers.  The VA represents the largest single healthcare system in the US, so the outcome – whatever it is – will have broad impact in all 50 states.

Second, what does “full practice authority” without “physician oversight” mean?  It is spelled out nicely.  Here’s the description:

“In proposed § 17.415(d)(1)(i), a Certified Nurse Practitioner would have full practice authority to provide the following services: comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases.

In proposed § 17.415(d)(1)(ii), a Certified Registered Nurse Anesthetist would have full practice authority to provide a patient’s anesthesia care and anesthesia related care, to include planning and initiating anesthetic techniques (general, regional, local) and sedation, providing post anesthesia evaluation and discharge; ordering and evaluating diagnostic tests; requesting consultations; performing point-of-care testing; and responding to emergency situations for airway management.

In proposed § 17.415(d)(1)(iii), a Clinical Nurse Specialist would have full practice authority to provide diagnosis and treatment of health or illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities within their scope of practice.

Lastly, in proposed § 17.415(d)(1)(iv), a Certified Nurse-Midwife would have full practice authority to provide a full range of primary health care services to women veterans, including gynecologic care, family planning service, preconception care (care that women veterans receive before becoming pregnant, including reducing the risk of birth defects and other problems such as the treatment of diabetes and high blood pressure), prenatal and postpartum care, childbirth, and care of a newborn… [and] include treating the partner of the female patient for sexually transmitted infection and reproductive health. We would include the services of a CNM in this rule making in anticipation that VA would hire CNMs at a future date to improve access to health care for the increasing number of female veterans.”

So, in my mind, instead of attacking one another, let’s consider the actual policy implications.  Some relevant questions are 1) whether the federal rules should pre-empt state laws about physician oversight, and 2) whether you think the above four paragraphs describe the practice of medicine or not.

laws determine scope of practice

The practice of nursing vs the practice of medicine

Many people are surprised to learn that legislation and rules like this actually determine scope of practice for just about all clinicians (physicians, chiropractors, nurses, etc).   As part of  the proposed rule, the “VA may grant full practice authority…and define the scope of full practice authority… VA intends that the services would be consistent with the nursing profession’s standards of practice.”   So, as long as the official bodies of the nursing profession say that certain activities are the practice of nursing, this VA rule can make it so, and they will overrule any existing laws in your state that say otherwise.  This is the same general process for establishing scope of practice for most healthcare professionals in their own domains (ex chiropractors, optometrists, podiatrists, pharmacists), although usually at the state level.

If those four definitions above describe nursing, then there is no reason to debate.   If the activities are the practice of medicine, then someone with a medical degree and medical training should be involved.  Obviously, not all clinicians agree on this, and I’m not sure what the patients think.   But without question, both medicine and nursing have evolved considerably over time, and will continue to do so forever.

What is the practice of medicine?   Here’s a New England Journal of Medicine article from 1937 on that subject, and a more recent discussion in JAMA.   We can consult everyone’s favorite – Wikipedia – or just turn on the TV and be inundated with ads reminding you that “this product is not intended to diagnose, treat, cure, or prevent any disease” – which are among what the FDA considers to be markers of “medicine”.

emergency surgery


Other key issues in healthcare are access to care and cost of care, which is clearly a problem.  As the rule emphasizes, cost and access are among the chief driving forces in the proposal: “This rulemaking would increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide health care… without the clinical supervision of physicians.”

This conversation gets so easily derailed into insults about one professional group vs another, which I think dishonors us all. The goal is to make healthcare better, safer, and easy to obtain when needed. Bonus points for controlling cost. We all want to give the very best care possible to our patients, regardless of education, training, or initials after our names.  Teamwork.

Just two weeks ago, at the IARS meeting, we were discussing the state of healthcare quality and safety research. In a somewhat paradoxical conversation, we agreed that the very best outcome of our work would be to make the practice of medicine and healthcare systems so safe and so good that we essentially make ourselves (doctors) obsolete. It would be fantastic to live in a world in which no one is harmed as a result of well-intended healthcare. Yet, just recently, there were major headlines about the study indicating that error is the #3 cause of death in the US.

If we can ever achieve a level of wellness, health, and healthcare safety such that physicians are no longer needed, it will be a great day for humanity.  I don’t think we are there yet.  But we are working on it.  

The VA wants input on this issue.  If you have an opinion, you must comment before July 25, 2016 at  (be sure to reference to  “RIN 2900-AP44-Advanced Practice Registered Nurses”).   You can also submit comments via or


  1. JC Lydon (@JcLydon) June 7, 2016 Reply

    Marjorie; while agreeing with most of what you said, I was disappointed that you did not outline your position on independent CRNA practice. Are you for or against physician led anesthesia care, the anesthesia care team model ? It is important for our academic leaders to state their position, in my humble opinion. Maybe I misread your post; if so, I apologize. Perhaps you could restate your position. I am on record as wanting to preserve the current state of practice for our specialty, which I believe is paramount for patient safety. And I say so with no vitriol or malice. Thanks.

    • Author
      Marjorie Stiegler July 29, 2016 Reply

      Hi JC – thank you for this comment! Yes, I agree completely that preserving access to physicians is critically important for safe care of our veterans and everyone else. I’ve elaborated a bit more on my reply in the dental post. Scope of practice should not be expanded by legislation. It should be earned by training and qualifications. But my blog is intended to inform rather than persuade readers of my own view. I hope people can read the objective information and make up their own minds, share their ideas, and discuss it with others so we can all be more educated on these issues.

  2. Rebecca June 8, 2016 Reply

    This basically SAYS IT ALL. An absolute inspiration to our profession! #CRNAStrong

    “My name is Susan M. Perry, PhD, CRNA, APRN, Colonel, USAF, NC retired. I served in the United States Military as an active duty officer for 25 years, retiring in December of 2014. For 16 of those years, I was a Certified Registered Nurse Anesthetist. For 8 of those years I served at the Uniformed Services University educating and training CRNAs for the Department of Defense. My position at retirement was Senior Air Force Faculty at the Daniel K. Inoyue Graduate School of Nursing. I also served as Consultant to the AF Surgeon General for CRNA Education. Now I am the Senior Assistant Dean for Clinical Graduate Studies at the University of South Florida.
    During my active duty time I was deployed 4 times. During all but one of those deployments I was the ONLY anesthesia provider at the deployed location. In fact, one of those times I was substituted for an anesthesiologist who obtained a “waiver” not to be deployed. Not one of those times did anyone question that I was able to administer anesthesia without supervision. I was deployed to Saudi Arabia to care for the entire Prince Sultan Airbase contingency operation. I was deployed to Qatar and performed independent anesthesia on the first wave of our OIF casualties, including our service dogs. I was deployed to Honduras in support of our special forces/humanitarian missions and was the anesthesia provider who developed the rotary wing aircraft surgical services contingency plan. I had all of our anesthesia training lectures translated for their school and led seminars on pediatric anesthesia for the anesthesia staff in the Honduran hospitals. There was NO other anesthesia provider there at any time. I was deployed to Peru as the operations commander.
    The men and women I saved, thousands of miles from home, now come to the VA for care. Who should be there to take care of them? The civilian anesthesiologist who were sleeping at home while I improvised a way to do surgery in a sand storm with no electricity? While I figured out how to administer anesthesia to a child when there was no oxygen for recovery? When I was stationed in Bitburg Germany with the closest anesthesiologist in England, and I raced in a snow storm to put in an IV and save a mother who was hemorrhaging and losing her baby, allowing both to survive? I don’t think so, I think CRNAs have been the anesthesia provider for over a 100 years and the anesthesiologist that have “supervised” the CRNAs have walked in, given breaks and in the cases of the one place I was deployed with an anesthesiologist? During the night that we had 3 special forces troops come in for surgery with gunshot injuries to the head and neck and we worked all through the night. The anesthesiologist called me in from my rest period to do anesthesia for the most severely wounded while she slept in the middle of the tent. I finally woke her up to take over at the end the case so I could get some sleep because I was coming on duty in 3 hours. To not allow CRNAs and other APRNS to practice independently is discrimination, pure and simple and should not be allowed in the United States of America and certainly not in the VA.

    Susan M. Perry, PhD, CRNA, ARNP, Colonel, USAF, NC retired
    Senior Assistant Dean Clinical Graduate Programs/Director CRNA Program
    University of South Florida College of Nursing”

  3. Author
    Marjorie Stiegler June 9, 2016 Reply

    Hi Ryan,
    Thanks for your email. I’m not sure I have what you are looking for, but I will try to describe a summary of the themes I am hearing and seeing online.

    As I hope I conveyed in the blog post, I think a lot of the strong feelings on both sides are probably linked to somehow feeling jeopardized or devalued, which I think is misplaced. Mostly, I have been aware of contentious exchanges informally (say, comments to an online news article, or Facebook posts), and I’d say that most of those are rooted more in emotion than fact or resources.

    Overall, I think the questions I hear most tend to fall along the lines of whether certain activities constitute practice of medicine or practice of nursing, and whether they reasonably fall within the scope of training. For example, is it a stretch for a nurse midwife to treat male infertility, as provided in the rule?

    My personal interest in this rule is more about healthcare evolution (past, present, and future), and in the legal perspectives over state law, federal law, and the VA system. The comment above concludes by saying that it is discrimination against nurses to not allow APRNs to practice independently. I’ve also heard the opposite – that effectively limiting veterans’ access to physicians is discriminatory to the patients. But, as with all of the landmark civil rights issues, cases of discrimination are ultimately decided by a national ruling of one sort or another. So it is an interesting question – is there discrimination, and if so, who is the target or victim of that discrimination?

    I have also heard people express concern that if some APRNs prefer a team model to independent practice, they would be forced out or deprived of privileges within the VA, if independent practice is mandated.

    Also, people on all sides have expressed concern about legal liability, and whether it is shared or falls solely on one clinician, and if so, which one? For example, there is this crazy case of an ophthalmologist, nurse anesthetist, and paramedic, with no one wanting to take responsibility for the patient’s death.

    One final theme I keep hearing is the possibility of a final common credentialing pathway that would take the wind out of all of these debates. For example, MD and DO physicians have distinct degrees and overlapping but different educational curricula in their respective medical schools, and yet they complete the same residency training and board certification process, so their “terminal” education and credentialing are identical. What if the nursing and medical boards merged to a single, unified governing body for all healthcare professionals, and then set identical standards for scope of practice and certification? It wouldn’t matter how a clinician entered their healthcare career. It would only matter that everyone ends on the same note of meeting whatever knowledge, experience, and testing standards are established.

    So that’s the buzz I’m hearing – all very interesting to consider. I’m sure there are other perspectives in addition to these. For formal documents and resources, as you asked, I believe that would be good place to look. I hope that’s helpful in answering your question as best I can.

    Thanks again for your email!

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