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The Department of Veterans Affairs would dramatically expand the authority of nurses to treat patients without a doctor’s supervision in a controversial <a href="https://www.federalregister.gov/articles/2016/05/25/2016-12338/advanced-practice-registered-nurses">proposal</a> by the country’s largest health-care system.

The plan, which would allow nurses with advanced training to broaden their responsibilities for patients, is drawing attention to a bitter debate over the relative roles of doctors and nurses. Because of VA’s high visibility, it is likely to be closely watched.

The agency, through amended regulations, wants to give vast 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.

[<a href="https://www.washingtonpost.com/news/wonk/wp/2016/03/18/in-a-fight-between-nurses-and-doctors-the-nurses-are-slowly-winning">In fight between nurses and doctors, the nurses are slowly winning.</a>]

VA would follow the lead of the military and 21 states and the District of Columbia that have expanded the scope of practice for nurse midwives, nurse practitioners and nurse anesthetists in a variety of medical fields.

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 29 states that still restrict what they can do, as long as they work for VA.

[<a href="https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/">VA chief compares waits for veteran care to Disneyland</a>]

The proposal was published this week in the Federal Register as a scandal over veterans’ long waits for medical appointments erupted anew. VA Secretary Robert McDonald was widely criticized for dismissing wait times as a proper measure of veterans’ satisfaction, comparing them with visitors to Disneyland who he said care more about the amusement park itself than how long they wait to go on a ride.

“The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future,” David J. Shulkin, VA’s undersecretary for health, said in a statement on the agency’s website.

About 6,500 of VA’s 93,000 nurses have advanced training and would see their duties expanded, officials said. The agency is trying to hire 3,800 doctors, but it is also short about 8,713 registered nurses.

Nurse practitioners are trained to provide many of the same primary care functions as doctors. But state laws have blocked them from diagnosing, prescribing drugs and other services.

[<a href="https://www.washingtonpost.com/news/storyline/wp/2015/01/13/more-nurses-are-better-for-patients-why-is-it-so-hard-to-get-hospitals-to-hire-them/">More nurses are better for patients. Why is to hard to get hospitals to hire them?</a>]

In its proposed rule, VA said its goal is to “increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services”  to the “full extent” of their education, training and certification.

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 nation’s top health care systems rely on physician-led teams to achieve improved care and patient health, while reducing costs,” Stephen R. Permut, board chair of the American Medical Association, the nation’s most prominent physician organization, said in a statement.

“We expect the same for our country’s veterans,” Permut said. ” All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine.”

The American Society of Anesthesiologists, which represents 53,000 physicians, also opposed the proposed policy, saying that “removing  anesthesiologists from surgery and replacing them with nurses” would be “lowering the standard of care and jeopardizing Veterans’ lives.”

The group said nurse anesthetists have half the education and a fraction of the training of physicians. The group plans to hold a press conference Wednesday to denounce the VA plan.

Asked at a hearing in March whether nurses would do the jobs of anesthesiologists under the change, McDonald and Shulkin assured House lawmakers that they would not. On Thursday, the lawmaker who asked the question, said he was misled.

“The secretary assured me, and I believed him,” said Rep. David Jolly (R-Fla.). VA officials could not immediately be reached for a response.

Military hospitals have long given nurses with advanced training similar authority. But opponents said the patient populations are very different. Active-duty soldiers and retirees tend to be in better health than many veterans.

“The average person who is active-duty military is generally in good health,” said Rupa Dainer, an anesthesiologist who practiced at military hospitals for 19 years and is now in private practice.

“The veteran population is different,” she said. “When a nurse has a patient with complications, they ask for help, but that’s not what would happen here.”

The American Association of Nurse Anesthetists said in a statement that VA would follow a common practice for combat nurses in the field.

“Improving the [Veterans Health Administration’s] ability to provide better, faster care to our veterans doesn’t necessarily require increasing budgets or staff,” the group’s president, Juan Quintana, said in a statement. “One solution has been there all along, and is as simple as removing bureaucratic barriers to [advanced-degree nurses’] ability to be credentialed and practice to the full extent of their education, training and certification.”

The American Nurses Association, in a statement, said longstanding limits on the scope of care for nurses with advanced training is what has harmed veterans, because staff shortages let backlogs and wait lists grow longer.

The proposed rule will be open for comment for 60 days.

Correction: An earlier version of this post misstated Stephen R. Permut’s role at the American Medical Association. He is the board chair. It also misstated the number of states that have not expanded nurses’ allowed services. The correct number is 29.

Wesleyan University, B.A. history

Lisa Rein covers federal agencies and the management of government in the Biden administration. At The Washington Post, she has written about the federal workforce; state politics and government in Annapolis, and in Richmond; local government in Fairfax County, Va.; and the redevelopment of Washington and its neighborhoods.

Lisa Rein

The Washington Post

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