Full Practice Authority Brings Better Quality Care for Veterans

In June 2017, Charlene Seale became the first nurse practitioner in Texas to take advantage of a recent a ruling from the U.S. Department of Veterans Affairs granting nurse practitioners Full Practice Authority (FPA). Seale now has the right, as she would in 22 other states and the District of Columbia, to practice at the full extent of her training at the VA, including the ability to make diagnoses and write prescriptions for her veteran patients.

“Nurse practitioners are not physicians,” Seale told the Amarillo Globe-News. “We don’t have all of the knowledge and expertise that they have. So, when we encounter something we’re unfamiliar with, we still work as a team with our physicians here in the facility to make sure our veterans get the best care. But it basically streamlines the care process.”

Nurse practitioners are prepared by their education and training to prescribe medicine, but 28 states, including Texas, still restrict NPs from practicing at the full extent of their capability.

The Veterans Affairs (VA) ruling is considered a victory for many nurses who point to stressors like the primary care gap to showcase the need for more organizations to lift these restrictions. The results could provide relief for states like Texas, which experienced intense strains on medical resources during Hurricane Harvey.

In fact, Texas, California and Florida are all restrictive practice states that have an increasing need for medical professionals to respond to recent natural disasters. Fortunately, each of these states has multiple military bases with VA hospitals, where NPs are able to provide medical care for veterans in need.

Learning from Seale’s experiences and other providers at the VA can help NPs at other organizations and hospitals become more aware of the scope of practice regulations and the impact it can have on nursing practice development and patient outcomes.

Earning full practice authority is not what nurse practitioners and critics might expect, according to Shelly S. de Peralta, DNP, AC-NP MSN, RN, who has worked at the VA Greater Los Angeles Healthcare System for 17 years.

The ruling states that “full practice authority is granted by VA upon demonstrating that the advanced educational, testing, and licensing requirements established in this rulemaking are met and upon the recommendation and approval of the medical executive committee when the provider is credentialed and privileged.”

De Peralta said most states have individual review processes for their nurse practitioners to be granted FPA. She serves as co-chair for an advanced practice nurse review board at the VA that oversees the credentialing and peer-review process for the system’s 80-plus nurse practitioners.

“Credentialing includes collecting signatures and proof of professional standards before going to the medical executive committee,” de Peralta said of California.

Texas, California and Florida are all restrictive practice states that have an increasing need for medical professionals to respond to recent natural disasters.

Among the controversies resulting from the ruling is the lack of inclusion for nurse anesthetists at the VA; the organization cited a sufficient number of Certified Registered Nurse Anesthetists  (CRNAs) in the field, and therefore found no necessity to grant them full practice authority. However, many organizations are actively working to apply the ruling to nurse anesthetists who care for veterans, and the VA is accepting and considering comments from professionals in the field who want to expand the application.

The VA is the largest employer of nurses in the United States, accounting for 93,500 registered and advance practice nurses at the time of the ruling in 2016. Academic partnerships, travel opportunities and professional development are just a few of the ways that the VA attracts nurses who feel called to serve vulnerable populations.

“The specific care needs you address at the VA really make an impact,” de Peralta said. “I feel that by treating service members, I am also contributing to serving my country.”

Working at the VA is known to bring a level of autonomy and educational opportunities that many nurse practitioners seek for growth and development. However, the VA acknowledged a need to retain more NPs at its facilities. The Full Practice Authority ruling is yet another incentive for NPs to join the ranks and stay at the VA for more years, according to Kristin Kopelson, MSN, RN, NP, FNP-BC, ACNP-BC, a primary care provider, lead nurse practitioner and site manager at VA Greater Los Angeles Primary and Ambulatory Care Clinics.

“Now we are able to work much more efficiently because we don’t have to wait around for a provider who doesn’t know the patient to sign orders or paperwork,” Kopelson said. “We can move more quickly to get the patients and the families what they need.”

She supervises a staff of 25 primary and specialty care NPs and has been recognized by the VA for high team performance in the Patient Centered Medical Home Model.

Kopelson and other supporters of FPA say the ruling increases efficiency, saves money and yields better patient outcomes for veterans.

De Peralta, who is a legislative liaison at the California Association of Nurse Practitioners, said the organization hopes to follow in the footsteps of the VA and bring prescriptive authority to California.

“Impacting health care starts with getting a seat at the table,” said Kathleen Woodruff, ANP, DNP, who practices in Baltimore and teaches pharmacology for nursing students at the USC Suzanne Dworak-Peck School of Social Work Department of Nursing.

Woodruff said she encourages her students to become involved in organizations that support nursing practice, like the American Association of Nurse Practitioners or a state level legislative board.

Supporters of FPA say the ruling increases efficiency, saves money and yields better patient outcomes for veterans.

For NPs who don’t yet have the right to practice at the full scope, Kopelson advised perseverance in facing the difficult road ahead. “Professionalism isn’t dictated by a piece of paper but by the behavior exhibited in conduct when collaborating with others,” she said.

For Woodruff, the bottom line of full practice authority is rooted in patient outcomes.

“These are people who have supported our country; they need the best care we can offer,” she said.