The VA takes heat over plan to let nurses treat vets without Doctor supervision-But at what price?

13343091_901654003297593_1945580382535353084_nDoug McKelway reviewed one of the solutions that the Veterans Affairs Department has come up with for the VA health care travesty. Their answer is to allow nurses to do the jobs of the physicians. The Veterans Affairs Department is taking heat over a proposal to allow highly trained nurses to act as doctors, and even administer anesthesia without a doctor’s supervision.

The move is part of an effort to reduce what is largely recognized as the VA’s greatest problem — long wait-times for doctor visits. But some see it as an ill-conceived plan that could put veterans at risk.

“When you have a veteran on the operating table with multiple medical conditions, seconds count,” said former president of the American Society of Anesthesiologists Dr. Jane Fitch, who was once a nurse herself.  “All those years of education and training can make the difference between life and death.”

Fitch was among a group of anesthesiologists who gathered at the National Press Club on Wednesday to express opposition to the VA’s proposed rule. “For the safety and health of all of our veterans, the proposed policy as written must be stopped,” she said.

The proposal could apply to any of the VA’s four categories of advanced practice nurses — Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist, or Certified Nurse-Midwife — although the agency later clarified its initial press release to explain that “At this time, VA is not seeking any change to [current] policy on the role of CRNAs, but would consider a policy change in the future to utilize full practice authority when and if such conditions require such a change.”

Over 6,000 of the VA’s 93,000 nurses would see their roles expanded under the plan, enabling them to perform diagnostic testing, prescribe medications and even administer anesthesia — a trend that’s also happening in the private sector.

In the proposed rule, posted in the Federal Register on May 25, the VA noted that Clinical Registered Nurse Anesthetists (CRNA’s) “have full practice authority in 17 states, while Clinical Nurse Practitioners (NPs) have full practice authority in almost 50% of the nation, which includes 21 states and the District of Columbia.”

The proposed rule is also meeting with political opposition. Rep. David Jolly, R-Fla., is outraged by the proposed change — noting that at a March 2 hearing, he specifically asked VA Secretary Robert McDonald  to “describe his position on it.”

McDonald responded, “The thing we feel least comfortable about is anesthesiologists.” But he left the door open to expanding their physician-like roles in the future, should the need arise.

In an interview with Fox News on Wednesday, Jolly accused McDonald of intentionally misleading Congress in his March 2 testimony. “I would go so far as to say we have been misled as a Congress and as a country by the VA secretary and by the Department of Veterans Affairs, who said they were not going to issue this rule, but in fact did,” he said.

That assurance was not good enough for the American Society of Anesthesiologists (ASA). “Although the press release was updated, that change is not reflected in the proposed policy that was posted to the Federal Register on May 25 granting full practice authority to all advanced practice registered nurses, including nurse anesthetists,” the ASA said in a statement. “Removing physician anesthesiologists from surgery and replacing them with nurses lowers the standard of care and jeopardizes Veterans’ lives.”

Dr. Daniel Cole, the president of the American Society of Anesthesiologists, maintains the proposed rule change is unnecessary. “There is no shortage of physician anesthesiologists in the VA,” he said.

He noted there are only seven job openings for anesthesiologists at the VA out of a total number of 1,188 employed  — well below the private hospital average.

The public comment period for the proposed rule change ends on July 25.

Now remember our discussion about the burnout problem within the physician groups? This next article by Carleen Wild pointing out that the nursing profession is feeling the same stresses. If we now give the care of our Veterans to nurses will it solve our problems?

If you take care of your people, the mission takes care of itself.

“You’re taught ‘you don’t show the chink in your armor, you don’t show weakness.’ So you push it all down. That’s not successful caregiving,” said Flarity.

This is the mantra that Kathleen Flarity, a career combat medic from Headquarters U.S. Air Force in Colorado and a research nurse scientist at UCHealth, says you’re taught when you enter the military. But she never thought she’d be applying the same principle to her profession.

Flarity, as of this year, has become a much in-demand speaker and instructor in the growing field of Compassion Fatigue Resiliency Training — meaning, burnout in the field of nursing.

“I’ve been watching people I care about suffer, and I was interested to know if there was something that could be done about it,” Flarity said.

“Compassion fatigue has two components: There’s the burnout component, and then there’s the secondary traumatic stress — the witnessing of pain and suffering of others. That’s inherent to anybody who chooses the caring profession,” she added.

Flarity says these issues have always existed in nursing. They’re just showing up now in new ways, including in a high turnover rate within the profession at a time when we need more nurses than ever. She only realized there was something going on back in 2003 after her best friend came back from an air medical evacuation deployment.

“He had difficulty personally and professionally. He was argumentative, had difficulty sleeping. He had flashbacks and avoidant behaviors, and he actually left the profession of nursing and the military after that,” said Flarity.

She began to search for an intervention and worked with Dr. Eric Gentry, a pioneer in the field, to develop a program. Flarity now uses her best friend’s story, detailed here in this YouTube video, when she talks with others.

“All the [health care] arenas teach stoicism and objectivity. You’re taught ‘you don’t show the chink in your armor, you don’t show weakness.’ So you push it all down. That’s not successful caregiving. People who are drawn to the caregiving profession tend to be more empathetic than others. And because of that, we’re more exposed to taking home the pain and suffering of others. All of that tends to build if you don’t work on the resiliency piece. If leadership doesn’t support the staff to make them feel valued, wanted, needed and address some of the burnout — this will only get worse.”

Health care systems are starting to see that Flarity and others who are advocating for a healthier workplace are onto something.

A recent Hospitals & Health Networks newsletter shared the attention being given to the nursing burnout epidemic, labeling it a “public health crisis” and citing a lack of leadership for the trend.

One reader, “eiggam2,” responded to one of the articles with these comments: “Nursing leadership is a root cause [of burnout] or lack thereof. The gap between those assigned to these leadership roles and those who perform actual nursing care is overwhelmingly wide and continues to broaden. Theoretically, we can invent pseudo solutions, which were dreamed up in some boardroom, but until we hand nursing back to nurses, we will be doomed to extinction.”

The article noted new initiatives some health care systems are taking to support nurses.

The Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, Illinois, recently developed five “renewal rooms” to help nurses rejuvenate and refresh while caring for patients.

Oncology nurses reported emotional exhaustion and low rates of personal accomplishment.

The renewals rooms include soft lighting, a soothing décor, a massage chair, aromatherapy, music therapy options, and journaling opportunities, CTCA said. Nurses use the rooms to get up to 15 minutes of privacy after a stressful event, or to simply recharge during a busy day.

The hospital made the investment after a 2011 study found that one-third of oncology nurses demonstrated emotional exhaustion and reported low rates of personal accomplishment, one-quarter reported depersonalization, and half reported levels of emotional distress.

CTCA may be onto something. In just the last few months, Flarity has started getting calls from 911 centers, fire departments, and other health care institutions to provide training for management and staff. This is in addition to the classroom teaching she does with nurse residents at UCHealth on three different campuses, and the work she is doing with her colleagues.

She reminds nurses what is within their circle of control, and helps them find ways to relax throughout their shift.

“You’re not going to add things onto an already busy day. But when they go to wash their hands, they can think about taking some slow, deep breaths. They can think about the warmth of the water — the soap, washing away the stress of the patient. They can be open to the next experience.”

If she’s helping others, Flarity says it’s an honor and very humbling. She is grateful and she and other people appreciate the training of the nursing profession and what they do daily. But her motivation is also to help this profession survive, one she has worked in for nearly four decades.

“If I am passionate and love what I do, the patients are going to feel that. I’m going to make fewer medical errors. I’m going to have more of myself in my job and the patients are going to feel it. So patient satisfaction, and satisfaction within the organization, is going to go up. So the bottom line goes up.”

The other reason that I bring this matter up is that it is one of the solutions to the Affordable Care sustainability crisis. The government architects and we are concerned physicians have found that we will have fewer physicians to care for the increasing population of patients now covered by the ACA health and therefore the solution is to have the care of those additional patients and probably most of our population cared for by nurses. This strategic solution is already part of the health care system in our European neighbors. It means that you may never see your physician or only in extreme cases will the physician be involved in your treatment.

Is this the solution that we all want or need?

Again I point out that if you want to see where we are going with the ACA look at how the VA and the government runs the care of our Veterans and our servicemen and women.

We can’t take short cuts and expect to deliver great health care to our patients. Looking at all that we have discussed on this site we need to develop a real set of strategic plans with actionable items that improve the health care system and support our physicians and nurses who will be delivering the care to all our patients.

Will we Americans need to institute additional income taxes, national sales taxes or even better a health care lottery to support a system that is non sustainable financially? Or can we develop a unique health care system available to all and sustainable, with a reasonable way of educating our physicians and nurses and workable tort reform?

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