VA makes it official: APRNs win full practice authority in final rule

The U.S. Department of Veterans Affairs will now allow three types of advanced practice registered nurses to practice to the top of their licenses without the clinical supervision of physicians, in a move intended to improve access to primary care providers within the agency's healthcare system.

This allows APRNs to take on role consistent with that of the non-VA healthcare sector, according to the federal agency. Cindy Cooke, DNP, president of the American Association of Nurse Practitioners, applauded the VA's decision.

"This final rule is a critical step for America's veterans to be able to obtain timely, high-quality care in the Veterans Health System," Dr. Cooke said in a statement. "We are pleased the VA will move forward with allowing veterans throughout the country to have direct access to nurse practitioner provided healthcare."

The three types of APRNs included in the final rule are certified nurse practitioners, clinical nurse specialists and certified nurse-midwives. Notably absent from the rule are certified registered nurse anesthetists.

The inclusion of CRNAs was controversial in the proposed rule, which was published in May. The American Society of Anesthesiologists in particular opposed the inclusion of CRNAs, claiming it would block veteran access to physician anesthesiologists. ASA said the VA's chiefs of anesthesiology felt the policy "would directly compromise patient safety and limit our ability to provide quality care to veterans."

The VA said it decided not to include CRNAs in the final rule because the healthcare system does not have a shortage of anesthesiology providers. It said this decision was not intended to reflect a position on CRNAs' ability to provide safe, high-quality care.

The ASA praised the final rule Tuesday. "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."

While the American Medical Association supported the exclusion of CRNAs from the final rule, President Andrew Gurman, MD, issued a statement of opposition. "[W]e are disappointed by the VA's decision today to allow most advanced practice nurses within the VA to practice independently of a physician's clinical oversight, regardless of individual state law," Dr. Gurman said. "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 rule, which is effective 30 days after publication, will be published in the Federal Register Dec. 14. The final rule is open for comment. Comments may be submitted online at, by mail or by hand. Find more information on how to submit a comment here.

Editor's note: This article was updated Dec. 14, at 9:00 a.m. CT to include a statement from Cindy Cooke, DNP.

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