The VA Granted Nurse Practitioners Full-Practice Authority & Doctors Are Outraged

The debate over full practice authority for Nurse Practitioners (NP) continues on as some Doctors oppose autonomy.

In December 2016, the Department of Veterans Affairs (VA) issued “full practice authority” to three roles of  APRNs (all except CRNAs were included) to work for the VA. The NPs were granted permission to practice independently without an overseeing physician and the decision overrode any state restrictions on NPs practicing independently, aside from a few exceptions, such as prescribing controlled substances. 

The move was met with some strong opinions on both sides. A January 2020 piece in MedPage Today, titled “VA Goes Too Far on NP Independence,” claimed that doctors’ morale has been “suffering” as a result of the decision, and warned that patient care may soon suffer as well. 

The American Association of Nurse Practitioners, on the other hand, supported the VA’s decision. When the announcement was made in 2016, the AANP released a statement on their website celebrating the news: “AANP applauds this move to provide our nation’s veterans with direct access to the health care services of NPs and other APRNs and encourages the VA to include our CRNA colleagues.”

The VA’s decision has proven to be just yet another fuel in the fire over the discussion of NPs practicing independently. For instance, in a response to the fact that NPs have tripled in Illinois–where they are allowed to practice independently–, a Feb 8th article in the Chicago Tribune posed the question “Should you be worried?”

And some physicians, such as the group, Physicians for Patient Protection, are actively fighting against any non-physician full practice authority healthcare practitioner. The group calls itself an advocacy group to “ensure physician-led care for all patients and to advocate for truth and transparency regarding healthcare practitioners” and has resources such as a reporting form for patients who believe they have been “mismanaged” by a non-physician practitioner and even “swag” that features its slogan of “brain, heart, and training of a doctor,” just in case its mission wasn’t clear. 

Opponents to NPs practicing independently cite the fact that the clinical training requirements are different for nurses and physicians and a 2014 study that found that non-physician providers ordered more imaging services than physicians. (However, a newer study in 2017 found that NPs working emergency room triage actually ordered fewer studies than physicians.) 

Proponents, on the other hand, point to the fact that NPs are often nurses with extensive clinical backgrounds outside of the minimum educational requirements and fill an important role as the physician shortage continues to increase. They also point to studies that support that NP care is safe and cost-effective. 

“If [NPs] have the ability to free up physicians to provide care for more complex patients, then utilizing an advanced practice registered nurse in those voids makes a lot of sense,” Susan Swart, the executive director of the Illinois Society for Advanced Practice Nursing. told the Chicago Tribune. 

Personally, I know that given the choice, I actually prefer to be seen by an NP for myself–I feel like I can relate more to an NP, I feel a little more comfortable that they can take their time with me, and I don’t feel as intimidated to ask questions. I have zero problems or concerns with being seen by an NP. But, on the flip side, I have also requested a see a specific doctor instead of the NP when my daughter was born a preemie, simply because I knew he had extensive experience that the NP did not. For me, personally, both were excellent providers that I trusted in different circumstances, a stance that many patients also seem to agree with. 

“I rarely see my doctor,” commented one woman in response to an article about NPs being granted independence. “ I get my treatment from a Nurse Practitioner or PA. The NP spends more time with me and listens more than the doctor.” 

“Why would anyone be worried?” wrote another. “What a ridiculous question! They go to school to advance from a nurse to a nurse practitioner! They are educated and competent medical professionals!”

Personal preference aside, what are the differences between physicians and NPs? Let’s take a look:

Education

• Nurse Practitioner: 4-year Bachelor’s in Nursing; Master’s of 2-4 years
• Physician: 4 years Bachelor’s (non-medical allowed); 4 years medical school in the doctoral program; 3-4 years residency

Clinical experience during training

• Nurse Practitioner: Varies; minimum is 500 hours for FNPs, as of 2016 standards
• Physician: Minimum 3 years residency; estimated at 9-10,00 hours

Practice authority 

• Nurse Practitioner: Varies by state; some states allow practice only under supervising physician, others allow full practice authority
• Physician: Full practice authority in all states

Licensure

• Nurse Practitioner: RN license and state-issued NP license
• Physician: State board-certified; specialty 

License renewal

• Nurse Practitioner: RN license renewal every 2 years; FNPS must recertify every 5 years; CE requirements every year.
• Physician: Varies by specialty and license type, but on average, license renewal occurs every 3-10 years; CE requirements every year

Prescription ability

• Nurse Practitioner: Can prescribe medication, sometimes only under the authority of a physician.
• Physician: Full prescriptive authority

It can’t be denied that there are differences in the way that NPs and physicians are prepared, but it also can’t be denied that NPs are not only increasing in numbers but that they are also filling a valuable role in areas of physician shortages, such as in rural communities. 

Between the years 2017-2018 alone, 28,700 new NPs joined the field and according to the most recent statistics, there are 270,000 NPs practicing in the U.S. right now. And as that number is only predicted to increase, maybe the movement will turn to taking an objective look to see if NP education and training needs to be evaluated or updated in light of more states allowing NP full practice authority or if additional policies are needed as more states make their own decisions about full practice authority. 

No matter what the future may hold for NPs and their ability to practice independently, one thing is clear: this is a discussion that is not going anywhere anytime soon.