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NP's do it again..... They are effective in the political realm.... if only AAPA can play catch up.


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Nurse Anesthetists Left Out of New VA Policy NPs, other advance practice RNs given full authority
 

WASHINGTON -- Nurse anesthetists will not be able to independently administer anesthesia -- at least as of now -- in Department of Veterans Affairs (VA) facilities under a final rule issued Tuesday that scaled back an earlier proposal.

"The Department of Veterans Affairs (VA) is amending its medical regulations to permit full practice authority of three roles of VA advanced practice registered nurses (APRN) when they are acting within the scope of their VA employment," the agency said in the rule. "Certified Registered Nurse Anesthetists (CRNA) will not be included in VA's full practice authority under this final rule, but comment is requested on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking."

Although nurse anesthetists did not get the go-ahead, three other types of advanced practice nurses did: certified nurse-midwives, nurse practitioners, and clinical nurse specialists. "By permitting [these] three APRN roles ... throughout the VHA [Veterans Health Administration] system with a way to achieve full practice authority in order to provide advanced nursing services to the full extent of their professional competence, VHA furthers its statutory mandate to provide quality health care to our nation's veterans," wrote the authors of the rule.

"This regulatory change to nursing policy permits three roles of APRNs to practice to the full extent of their education, training and certification, without the clinical supervision or mandatory collaboration of physicians."

The rule has been the subject of some controversy. "We feel this proposal will significantly undermine the delivery of care within the VA," Stephen Permut, MD, JD, chair of the American Medical Association's (AMA) board of trustees, said in a statement this past spring when the proposed rule was first issued, adding that the association was "disappointed" by the VA's "unprecedented proposal."

"The AMA urges the VA to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes," Permut said then.

Responding to the final rule, the American Society of Anesthesiologists (ASA) praised the decision to withhold full authority from nurse anesthetists. "This was the right decision for our nation's veterans and for safe patient care," ASA President Jeffrey Plagenhoef, MD, said in a statement. "We're thrilled with the VA's decision to remove anesthesia from the new Advanced Practice Registered Nurses rule.

"We commend VA's leadership for their recognition that the operating room is a unique care setting and that surgery and anesthesia are inherently dangerous, requiring physician leadership. This is true for anyone, but especially for our nation's veterans, given many of them have multiple medical conditions that put them at greater risk for complications during and after surgery and anesthesia."

The AMA also praised the decision. “The AMA is pleased that the VA final rule continues to recognize the critical need for collaboration among physicians and nurse anesthetists to ensure patient safety when delivering anesthesia care,” AMA president Andrew Gurman, MD, said in a statement.

However, he added, the association is not happy that other advanced practice nurses will be able to practice independently within the VA. “This part of the VA’s final rule will rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system.”

The American Association of Nurse Anesthetists was not able to respond by press time to a request for comment on the final rule. The group had backed the original proposal. "Our veterans are waiting too long to get the healthcare they have earned and they deserve," Juan Quintana, CRNA, president of American Association of Nurse Anesthetists, in Park Ridge, Ill., said at a June briefing. "We, as advance practice registered nurses (APRNs), all realize we're ready and capable [of providing] the services that are necessary for our veterans today."

The VA gave some background on its decision to leave the nurse anesthetists out of getting full practice authority. "We received 104,256 comments against granting full practice authority to VA CRNAs," the authors noted. "The American Society of Anesthesiologists lobbied heavily against VA CRNAs having full practice authority. They established a website that would facilitate comments against the CRNAs, which went as far as providing the language for the comment. These comments were not substantive in nature and were akin to votes in a ballot box."

 

"The main argument against the VA CRNAs was that by granting CRNAs full practice authority VA would be eliminating the team-based concept of care in anesthesia ... Team-based care was not addressed in the proposed rule because we consider it to be an integral part in addressing all of a veteran's health care needs. Establishing full practice authority to VA APRNs, including CRNAs, would not eliminate any well-established team-based care."

On the other hand, "The second argument posed against granting full practice authority to VA CRNAs was that there is 'no shortage of physician anesthesiologists in VA and the current system allows for sufficient flexibility to address the needs of all VA hospitals,'" the rule continued. "VA does believe that evidence exists that there is not currently a shortage of anesthesiologists that critically impacts access to care, and therefore VA agrees with the sentiment of this argument."

As a result of the agency's analysis, "We will, therefore, not finalize the provision including CRNAs in the rule as one of the APRN roles that may be granted full practice authority at this time. However, we request comment on this decision," wrote the authors. "If we learn of access problems in the area of anesthesia care in specific facilities or more generally that would benefit from advanced practice authority, now or in the future, or if other relevant circumstances change, we will consider a follow-up rulemaking to address granting full practice authority to CRNAs."

The public has 30 days from the final rule's official publication on Wednesday to weigh in on it. Comments can be submitted through this website beginning Wednesday.

 

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The VA has a centralized critical care management facility in Ohio where they remotely monitor VA critical care beds in VA Medical Centers throughout the nation.  They have cameras in every room and can write orders for nursing staff. The Ohio center refuses to hire PAs but they do hire NPs extensively. The VA is working slowly to eliminate the PA from its ranks. The announcement above is just the latest in ongoing steps to decimate the ranks of the PA at the VA. The response by the AAPA is too little too late. The most influential figure to help our profession advance in the VA, Dennie Woodmansee, is silent. Mr Woodmansee is however actively involved in the advancement of ongoing PANRE certification exams at the NCCPA, a policy that the AAPA and the majority of PAs oppose. Do you see why this battle is lost?

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The AAPA was "supposed" to have gotten PAs included in the original language.  Obviously they failed at that.  It would have been 100x easier if they had done so but now the AAPA will have to start from ground zero and start the process for the very beginning for PAs.  If the AAPA couldn't get PAs added to the language of this rule then how on earth will they be able to get an entire separate rule enacted for PAs?  I'll be shocked if in a year from now they have gotten PAs included.  In fact, I'll bet that I could enroll in NP school and graduate quicker than the AAPA gets this fixed. 

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I know the rule is not going to change before it is enacted, but at least the VA can know that we are paying attention and expect to see a correction in the future. There are already over 600 comments from nurses, mostly CRNAs. I encourage you to use this link to make your voice heard. 

 

https://www.regulations.gov/document?D=VA-2016-VHA-0011-178740

 

 

Dear Secretary McDonald:

 

As a Veteran with 25 years of military service, as a former U.S. NAVY Independent Duty Corpsman, as a consumer of VA health care, and finally as a student currently enrolled in a master’s degree PA (Physician Assistant) Program, I am writing to express my disappointment with the Dept. of Veterans Affairs' final rule on Advanced Practice Registered Nurses. (RIN 2900-AP44).

 

I find it appallingly short sighted and highly questionable that this rule excluded the PA profession. PA's are the most highly trained and clinically competent Non-physician providers in practice today. PAs are trained in the medical model just as doctors, frequently attending the same classes and passing the same exams. Compared to APRNs, PAs typically have over 4 times the classroom instruction in medicine, and over 4 times as many hours of supervised clinical rotations. This despite the fact that APRNs are typically awarded Doctorate degrees and PAs are awarded Masters degrees. The argument that APRNs have years of experience as practicing nurses prior to pursuing APRN is no longer true. Many APRNs programs are direct entry programs with no prior clinical experience required. Many are conducted entirely online and rely on the student to arrange their own clinical experiences.

 

I point out this disparity in training and education not to denigrate APRNs or question their clinical competence. My purpose is to point out the lack of any logical reasoning to grant autonomy to APRNs and not include PAs who have a higher standard of training based on a more relevant medical model and more supervised clinical experience. I have worked with and received care from many APRNs throughout my military career, including CRNAs who practice completely autonomously in many military settings and have the highest educational standards of any of the Advanced Practice Nursing professions, and yet CRNAs were also excluded from your rule. Clearly the drafting of this rule was not based on an assessment of the depth of training or clinical experience of non-physician providers. It was instead based on the political clout of the nursing community.

 

It is apparent that this rule was drafted and brought into effect through the efforts of the nursing community who have significant and influential management positions in the VA Medical System and healthcare as a whole. This combined with their significant lobbying presence has resulted in an environment where APRNs are achieving an increased level of autonomy compared to PAs which is not justified by any clinical, academic, or scientific data. Their sleight of hand in maintaining that they practice "Advanced Nursing" and as such should be regulated by state Nursing Boards instead of state Medical Boards is simply inconsistent with the realities of the clinical care they are providing and that the VA system is relying on them to provide. They ARE practicing medicine.

 

The Veteran's Administration has done a great disservice to the legacy of the veteran medics who returned from war and went to work with Dr. Stead to create the PA profession 50 years ago.

 

PAs deserve clinical parity with APRNs. I urge the VA to act promptly to correct this injustice. Immediately generate a new rule which will insert PAs as well as CRNAs into the language of this rule granting parity among all non-physician providers serving our veterans.

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AAPA tried to get ahead of this one, but just did not get there.... They tried and that is 100% better then the past

 

They are continuing to try (and I think NCCPA MUST come out with a IM CAQ, and we must have a terminal professional doctorate)

 

Keep trying, bummer we were not included but this is the nurses pushing, pushing, and pushing, and we just have to learn from them and do the same...

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The one thing I keep wondering: is the nursing lobby eventually going to push too far?  Therefore is it actually a good thing for us to blindly follow them?  Maybe it is better that we don't just get added to their rules/laws.  Isn't it better if we could have our own.  We don't want to be considered equivalent, we want to be considered better.

 

Our healthcare system is broken, both for patients and providers, there is no question about that, and NPs and PAs both have their role to play in the far future - but to equate ourselves to physicians is ridiculous.  Not because we are worse providers, or couldn't have become physicians, but we do not receive the same level of education in school as physicians (and of course NPs generally don't receive the level of education PAs do).  Do I think that there should be a path to independent practice?  Probably, but I honestly don't know exactly how that would work.  I have read some different ideas on here and they seem like a start, but I just get this feeling that nurses are pushing too far and are going to end up losing.  But, maybe that's just wishful thinking.   I wish it wasn't a competition, but it is - and until the AAPA and NCCPA realize that we will continue to lose.

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AAPA tried to get ahead of this one, but just did not get there.... They tried and that is 100% better then the past

 

They are continuing to try (and I think NCCPA MUST come out with a IM CAQ, and we must have a terminal professional doctorate)

 

Keep trying, bummer we were not included but this is the nurses pushing, pushing, and pushing, and we just have to learn from them and do the same...

I am tired of this. I am considering how to leave the profession entirely. It is a shame because I love medicine. Most of all, I love the study of medicine which few NPs actually spend time doing; that is studying medicine. Being smart, being prepared, being competent; none of that matters when you are outnumbered by a political engine that will roll over you, Becoming a PA was one a great mistakes of my life. I still remember thinking before PA school that I could have chosen NP but thought I wanted a more rigorous education. I actually loved studying organic chem and biochem prior to PA school. I loved the medical model. None of that matters. PAs are going to end up being supervised by Doctorate NPs. This is the beginning of the end for us. 

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A word to the wise.  I was evidently kicked out of the AAPA for voicing my concerns about the AAPA with regard to their failure on the VA Full Practice Authority issue.  When I tried to log in to Huddle this afternoon I was notified that "your account has been disabled."  Good riddance, they were a waste of dues money anyway if they are so sensitive as to get their collective feelings hurt that easily and ban me rather than engage in open discussion and debate.  If the AAPA were to go after the NP lobby as aggressively as their own members then they might actually get something done and win one of these battles instead of lose every time as if that was the intent.

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I never went on the Huddle because it is completely exposed and a resource for employers or whomever to use that data like social media.

 

I truly enjoy some anonymity here so I can express myself without fear of retaliation or "screenshots" with my name being used against me.

 

I won't jump to conclusions but would like to see how AAPA handles this.

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I am tired of this. I am considering how to leave the profession entirely. It is a shame because I love medicine. Most of all, I love the study of medicine which few NPs actually spend time doing; that is studying medicine. Being smart, being prepared, being competent; none of that matters when you are outnumbered by a political engine that will roll over you, Becoming a PA was one a great mistakes of my life. I still remember thinking before PA school that I could have chosen NP but thought I wanted a more rigorous education. I actually loved studying organic chem and biochem prior to PA school. I loved the medical model. None of that matters. PAs are going to end up being supervised by Doctorate NPs. This is the beginning of the end for us.

I totally could see this happening.

 

Sent from my SAMSUNG-SM-N920A using Tapatalk

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Posted about 11 PM Eastern on Huddle:

Dear AAPA Members, 

If you tried to login to Huddle today (Thursday) between 4:30 and 8:00 PM, you were greeted with a rather confusing error message. A coding glitch in an update caused our login verification process to completely shut down, impacting all members. The issue has been fixed and everyone should once again have access to Huddle. 

We apologize for the inconvenience, and thank you for your patience as we worked to resolve the problem.

Best regards,

------------------------------
Catherine Gahres
Vice President, Membership Development & Services
American Academy of PAs
Alexandria VA
------------------------------
 
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It is easy to get discouraged, not just with this setback, but with so much else in our world.

 

People who get discouraged easily aren't the ones who make progress for us all. It takes optimism, determination, and the ability to deal with setbacks. Sometimes that requires some downtime to rest, refuel, and rearm. Then, get back at it! (Maybe find a progressive state and concentrate on it for a while.)

 

And don't be a fair weather fan who only cheers for a team when it wins. The AAPA isn't perfect, but then again, neither is any other organization. Stand with them and encourage them to get back into the fray. 

 

100,000 plus PAs are in this fight, whether they all know it or not. Don't give up.

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It is easy to get discouraged, not just with this setback, but with so much else in our world.

 

People who get discouraged easily aren't the ones who make progress for us all. It takes optimism, determination, and the ability to deal with setbacks. Sometimes that requires some downtime to rest, refuel, and rearm. Then, get back at it! (Maybe find a progressive state and concentrate on it for a while.)

 

And don't be a fair weather fan who only cheers for a team when it wins. The AAPA isn't perfect, but then again, neither is any other organization. Stand with them and encourage them to get back into the fray. 

 

100,000 plus PAs are in this fight, whether they all know it or not. Don't give up.

 

I agree, however I'm waiting to see one major AAPA victory while we sit on the sidelines and watch the NPs "go long" complete the hail Mary and then spike the football in the endzone.  All of this while we PAs watch from the bench, on the sidelines with our helmets in our hands.

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I am tired of this. I am considering how to leave the profession entirely. It is a shame because I love medicine. Most of all, I love the study of medicine which few NPs actually spend time doing; that is studying medicine. Being smart, being prepared, being competent; none of that matters when you are outnumbered by a political engine that will roll over you, Becoming a PA was one a great mistakes of my life. I still remember thinking before PA school that I could have chosen NP but thought I wanted a more rigorous education. I actually loved studying organic chem and biochem prior to PA school. I loved the medical model. None of that matters. PAs are going to end up being supervised by Doctorate NPs. This is the beginning of the end for us. 

 

 

Once again - AAPA was alseep at the wheel and put us behind - but no longer - they are working HARD to establish PA as it's own profession which answers to only it self...... it will not change overnight, but it WILL change.....

 

 

 

 

 

A word to the wise.  I was evidently kicked out of the AAPA for voicing my concerns about the AAPA with regard to their failure on the VA Full Practice Authority issue.  When I tried to log in to Huddle this afternoon I was notified that "your account has been disabled."  Good riddance, they were a waste of dues money anyway if they are so sensitive as to get their collective feelings hurt that easily and ban me rather than engage in open discussion and debate.  If the AAPA were to go after the NP lobby as aggressively as their own members then they might actually get something done and win one of these battles instead of lose every time as if that was the intent.

 

 

 

was a glitch

 

As for HUddle - went on  few times - got yelled at for discussing anything about money - promptly left.... waste of my time....

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I never went on the Huddle because it is completely exposed and a resource for employers or whomever to use that data like social media.

 

I truly enjoy some anonymity here so I can express myself without fear of retaliation or "screenshots" with my name being used against me.

 

I won't jump to conclusions but would like to see how AAPA handles this.

 

And this is why we will continue to keep it this way for forum members who choose anonymity :)

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The AAPA is like the pedophile priest at the your local Catholic Parish. They do harm to others for a long time. (AAPA refuses to fight for practice independence, refuse to fight against unnecessary PANRE testing, etc)  Suddenly, a spotlight is shone on their bad behavior. (VA makes NPs independent while PAs remain dependent) They have an awakening. ( AAPA writes a posting on their website outcrying the move) The scales fall from their eyes and they now promise to do good and harm no person again. (AAPA sends a letter to the VA. oh my!) All is well. Trust your local pedophile priest? Then keep donating the AAPA who is destroying your professional future. Don't trust your local pedophile priest? Then quit supporting the AAPA.

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The AAPA is like the pedophile priest at the your local Catholic Parish. They do harm to others for a long time. (AAPA refuses to fight for practice independence, refuse to fight against unnecessary PANRE testing, etc)  Suddenly, a spotlight is shone on their bad behavior. (VA makes NPs independent while PAs remain dependent) They have an awakening. ( AAPA writes a posting on their website outcrying the move) The scales fall from their eyes and they now promise to do good and harm no person again. (AAPA sends a letter to the VA. oh my!) All is well. Trust your local pedophile priest? Then keep donating the AAPA who is destroying your professional future. Don't trust your local pedophile priest? Then quit supporting the AAPA.

 

 

not really true

 

this did not happen overnight

 

Myself and many other "long in the tooth" PA's have been hounding AAPA for over 5 years, many have taken positions with in the AAPA, some appointed, some elected.....

 

AAPA is not a single person, it is a grouping of people - whom have changed - and they are "seeing the light"

 

 

 

I go back to my same old statement - fine - dislike AAPA - but DO SOMETHING in the political realm (that means spending money!)   

So join your state chapter, do the political outreach, send in money to a PAC (only one national is AAPA) and FORCE AAPA to listen to the PA's in the trenches - - it does no good to be the contrary one then do NOTHING to support change....

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The AAPA is like the pedophile priest at the your local Catholic Parish. They do harm to others for a long time. (AAPA refuses to fight for practice independence, refuse to fight against unnecessary PANRE testing, etc) Suddenly, a spotlight is shone on their bad behavior. (VA makes NPs independent while PAs remain dependent) They have an awakening. ( AAPA writes a posting on their website outcrying the move) The scales fall from their eyes and they now promise to do good and harm no person again. (AAPA sends a letter to the VA. oh my!) All is well. Trust your local pedophile priest? Then keep donating the AAPA who is destroying your professional future. Don't trust your local pedophile priest? Then quit supporting the AAPA.

Thanks for the dose of doom and gloom. So, have you exited the profession? Seems how the end is near and all.. I plan on being involved in my state association and trying to make a difference instead of running around and yelling that the sky is falling. Do something about it... I would like to think that most new graduates are not naive about the challenges of real clinical practice and the job environment between PA/NP's. Some folks have been around the block a few times before attending PA school. You seem to be passionate, especially in describing your hatred for the AAPA, use it! Maybe you could be the next president of the AAPA and make some real changes?

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  • 3 weeks later...

This may be a portent of the future; a position was recently posted for a Cardiology PA at my VA facility.  The posting closed, but no one was interviewed.  I inquired about it today, and it seems as if the position is being "rethought" as better for a nurse practitioner.  There is little continuity of providers in that department, with residents and fellows coming and going, and I believe there is a concern for supervision.  The answer I got from administration was very convoluted, but one phrase that stood out was "this is not the place for a PA".

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This may be a portent of the future; a position was recently posted for a Cardiology PA at my VA facility.  The posting closed, but no one was interviewed.  I inquired about it today, and it seems as if the position is being "rethought" as better for a nurse practitioner.  There is little continuity of providers in that department, with residents and fellows coming and going, and I believe there is a concern for supervision.  The answer I got from administration was very convoluted, but one phrase that stood out was "this is not the place for a PA".

When the VA made Nurse Practitioners independent providers and rendered the PAs as dependent providers, the future was set for a fast decline of the PA in the VA. This was a deliberate move to eliminate the PA profession from the VA. It is widespread, not only at the OP's facility. What surprised most PAs is that the national chief of all PAs is Denni Woodmansee in Washington DC. There has not been a peep from his office about this or the future of the PA profession in the VA. Hence, it is clear that he has thrown in the towel. 

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When the VA made Nurse Practitioners independent providers and rendered the PAs as dependent providers, the future was set for a fast decline of the PA in the VA. This was a deliberate move to eliminate the PA profession from the VA. It is widespread, not only at the OP's facility. What surprised most PAs is that the national chief of all PAs is Denni Woodmansee in Washington DC. There has not been a peep from his office about this or the future of the PA profession in the VA. Hence, it is clear that he has thrown in the towel.

 

Please find a new profession and take your doom and gloom with you.

It is obvious that you hate it, see no hope and have nothing good to say or act on.

The rest of us are trying to persevere.

Find something good for you and move on.

Your bitterness is toxic to the profession.

Thanks

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