All across America and around the world, this is Veterans Radio.
Welcome to Veterans Radio.
I am Jim Fausone with veteransradio.org.
We're recording today from the Legal Help for Veterans Studio in Northville, Michigan.
Legal Help for Veterans is a Veterans Disability Law Firm.
And you can reach us at 800-69-34800.
We're really happy today to have on Veterans Radio a quite distinguished guest who's going
to help shed some light on what is being called one of the hottest battles in Washington over
VA's plan to expand nurses' powers.
We have with us Juan Quintana, who is the President of the American Association of
Nurses and Nestotys.
He holds a doctorate degree from TCU and a master's degree from Texas-Wesleyan University.
He is a veteran as well, so he certainly can relate to our listeners and family members
of veterans here on Veterans Radio.
Juan, welcome to Veterans Radio.
Hey, Jim, thank you very much.
I appreciate the invitation to join you.
It is certainly my pleasure to address veterans across the country and to say thanks.
Thanks for your service.
Thanks for everything that you've given to this great nation.
We're proud to serve you.
Well, let's talk just briefly about your nine or 10 years that you did in the United
States Air Force Reserves.
Tell us a little bit about what you did.
Sure.
You know, as part of my being a reservist in the 59th Medical Wing at Lackland Air Force
Base in Wilford Hall was to, in fact, provide anesthesia services while I was there.
So we cared for veterans there in the facility with all kinds of medical issues, primarily
issues that related to surgery.
We provided the anesthesia and, as always, thought to do our very best for all of the
servicemen who were coming through and meeting particular fixes for different issues and
the family members as well.
Well, Juan, you completed your service as a captain in the United States Air Force Reserves,
went on to practice and continue to practice in the great state of Texas, and you're a
certified registered nurse anesthetist or C-R-N-A. Can you explain to our listeners what that
designation means and what the job role and responsibilities are?
Sure.
I think, you know, I'd like to back up just for your listeners just a little bit and
talk about what APRNs are.
Those are advanced practice registered nurses.
And under that umbrella are nurse practitioners, certified registered nurse anesthetists, midwives,
and clinical nurse specialists.
All of us are considered advanced practice registered nurses.
C-R-N-A specifically in this country are approximately 50,000 strong.
We provide anesthesia services to the tune of approximately 40 million surgical procedures
per year.
In those, we provide services all the way from patients who are infants to our geriatric
population.
We administer them at all kinds of locations, big hospitals, suburban hospitals, community
hospitals, and down to the rural sector.
And in fact, for our veterans, C-R-N-A's are located in just about all the facilities that
administer or have surgical services associated with them.
In some, C-R-N-A's are the only anesthesia provider.
And in, for example, full-width surgical teams, C-R-N-A's provide those services to those
servicemen who find themselves in harm's way out on the battlefront.
So before we zero in on C-R-N-A's a little bit more, thanks for backing us up to advanced
practice RNs.
Do you have an idea of how many advanced practice nurses there are in the United States?
Today, Jim, there's approximately, I'm getting closer because I don't have all the nurse practitioner
numbers, but there are approximately 210,000 APRNs across the nation today.
Again, they work in all settings, different environments, providing all types of services,
and sometimes in association with physicians, sometimes separately.
So the services are readily available and out there with lots of data to show that we're
doing fantastic work out there.
That's the trick, right?
It absolutely is.
We're talking to Dr. Quintana, who is the president of the American Association of Nurse
Anesthetists.
Juan, in terms of the training that one goes, I assume for each of those four specialty
groups, the training to be advanced practice nurses is a little bit different, but could
you kind of tell our listeners the enhanced level of education and training that advanced
practice nurses have?
Sure.
All advanced practice nurses move through a system whereby they obtain registered nurse
license in their state, and from there, either they'll have a bachelor's degree or some kind
of bachelor's degree that's attributed to that.
From there, they move into masters, and now primarily all advanced practice registered
nurses are moving to doctorly prepared levels.
In fact, in the near future, anyone graduating from an APRN with an APRN degree will have
a doctorly prepared degree behind their name.
That involves a significant amount of hours with patients in clinics, seeing different
types of patients, different age groups depending on your specialty, and for example, in anesthesia,
providing anesthesia services for all ages in all settings.
It's a fairly intense system whereby we gain knowledge and experience very similar to our
physician colleagues and thereby serve the community with excellent outcomes, and all
our studies show that.
In the specific area for CRNAs, tell us a little bit more about how long it might take
to become a CRNA and are there special educational schools for this sort of thing?
How does one become a CRNA?
Yes, you know, becoming a CRNA, and I'll let you in on something, it's one of the toughest
things I have ever done in my life.
An intense form of education that I really, I was surprised, I knew I was up for it, and
it was a ton of work.
But the time component to it, from the time you receive your bachelor's degree, after
in terms of anesthesia education, we also require that you have at least at minimum
one year of intensive care unit training.
And so that means being with patients at least eight hours, 12 hours a day, sometimes longer,
while they're in critical shape, you know, sometimes often after open heart surgery,
lung surgery, craniotomies where they've had some kind of neurologic problem, issues like
that.
So once you spend that year doing that, then at minimum, and what we find is on average,
most CRNAs have approximately three years of intensive care unit training.
Then you apply to the program and you spend what is currently an average of about 30 months
to do it, but will soon be at minimum 36 months, so three more years.
On average right now, we could say that the CRNA is spending approximately nine years
to achieve a CRNA designation.
It's kind of a long track.
Yeah, these are highly specialized nurses in this area of advanced practice, any of those
four.
And is this, you know, for those of us who maybe aren't really all that familiar with
it, is this a new thing?
How long have there been CRNAs or advanced practice registered nurses?
You know, the designation CRNA is something that we started using, I guess, approximately
in two, in the 1930s, something like that.
But even prior to that, nurses administering anesthesia can be attributed all the way back
to the Civil War, where nurses were administering anesthesia to those servicemen.
So it's been around for approximately 150 years, and we're not new to the area of health
care at all.
Over the years, we've become more specialized, doing a lot more research, and doing a lot
more work so that today.
You know, if you compare anesthesia, perhaps, from the 80s, we're about 30 times safer than
we ever were then.
This gives you a sense of how progress, technology, all intertwined to achieve a super result,
combined with the outstanding education we have, and we have great results.
Wow, that's an incredible fact, and I can only imagine that as technology moves forward,
as it has over the last decade or two, that's made its way into your field, and probably
has helped on generating those great outcomes.
Oh, yeah, absolutely.
We have to think that in the past, if you went back just not too long ago, it was only
a physician could take your blood pressure.
That was considered the physician's purview.
Now today, you know, you and I know, you can go into Walmart and get your blood pressure
taken.
So it's a bit different today.
We've seen a lot of overlap, and we see that technology now is moving forward to help with
that as well.
We see that more and more, we can utilize the newer technologies to create a safer environment
for patients, to teach us more about patients, and to deal with things that in the past,
perhaps we would not have been able to do.
So speaking to Dr. Quintana, who is the President of the American Association of Nurse Anesthetists
and is a former captain of the United States Air Force Reserves, I want to back up to a
comment that you made that we maybe went a little too fast on.
How are CRNAs and advanced practice nurses being used by the Department of Defense?
In the Department of Defense, at least in terms of, and I can't speak wholly to the
nurse practitioner role, but I think it's pretty much like that, they are used to the
full capabilities of their education.
Why?
Because it just makes sense.
And so, for example, CRNAs are utilized, as I mentioned earlier, forward surgical teams
in different hospital settings, combined sometimes with anesthesiologists, at times without anesthesiologists,
but each of them working to their full capabilities, that just makes sense for the military.
It's a very reasonable approach, and as you can imagine, unless it was safe, it's highly
doubtful that they would adhere to it as much as they do.
Well, that brings us on to VA's proposal that has caused, as I mentioned at the outset,
quite a stir.
The Department of Veterans Affairs Office of Nursing Services proposed a new policy
document known as the VHA Nursing Handbook, and the principal purpose of that document
is to expand the role of advanced practice registered nurses in VA healthcare facilities.
And that's out as a new rule, as I understand it, and as just reported in Stars and Stripes
and the McClatchy Washington Bureau news release in like a week, 11,700 public comments were
lodged regarding this rule making, making it the hottest topic in the federal regulatory
world.
Who would have thought that would be such a hot topic?
But it seeks to have VA create the opportunity to use advanced practice nurses and CRNAs as
a subset there to the fullest extent possible.
Is this something that the American Association of Nurse Anesthetists supports, Dr. Contana?
Absolutely, we support it.
We are all aware through media, through our own experiences, that sometimes the wait times
at the VA service centers are and can be fairly terrible.
We know through the information that we have received that sometimes veterans are waiting
for their services to the detriment that potentially in some cases have lost their
lives because of it.
So what has happened over the last few years is that nursing in cooperation with the Institute
of Medicine have really determined nurses could make a significant impact in alleviating
these waits and hopefully getting access to services to veterans who really need that
care.
So as part of it, we've evaluated ourselves and nursing has evaluated itself and said,
hey, what's our quality?
How good are we at doing what we do?
And certainly when we've done that, study after study shows us that gosh, we're pretty
darn good at what we're doing, which is not in any way saying that our physician colleagues
are, but there's just not enough of them.
And so if we're both delivering outstanding services, then we need to get those services
to the patients, to the VACs who need that service.
The American Association of Nursing, of course, concurs with that 100%.
There are approximately almost a thousand CRNAs in the VA system.
And in some cases and in some hospitals, CRNAs have been the sole providers of anesthesia
services for an extended period of time.
We know that those outcomes from those individuals have been very good.
And so while we see these delays, we as a nursing group, APRNs, came to the VA and said,
hey, we can help with that.
We can make it less of a problem.
We can get those services to those veterans and alleviate some of these wait times.
From our perspective, the veterans have earned it and they deserve that care.
And it's our job to make sure that the veterans don't become the victims of this issue.
So we absolutely support it.
Dr. Chintana, the outcomes you're talking about, have they been studied and peer reviewed
by third party entities to confirm up that the treatment I'm going to get, the medical
care I'm going to get, is going to be delivered as well if it's an anesthesiologist or if
it's a nurse anesthetist?
Absolutely.
And we've done several studies.
We did them in 2009 where we evaluated it.
We evaluated again in 2011 doing a little slightly different comparison.
And then most recently, we actually evaluated, which was just published in medical care,
which is a manuscript that is published in the journal.
And it compared the scope of practice, that is, the practice of each CRNA in different
locations and basically different states.
And what they did was they compared the really restrictive ones as compared to the extremely
liberal in terms of permitting the CRNA to practice to the top of their educational level.
In the comparisons, they found no difference in the care in one versus the other.
That actually just affirms what we have always thought, that in fact, CRNAs and our anesthesiologist
colleagues are administering excellent anesthesia today 30 times better than it was in the 80s
and safer today than it ever has been.
And so what our position is, quite frankly, that we need to make sure that we're getting
those services to the veterans.
We continue to hear about issues like delays in cardiac surgery, GI scoping, endoscopic
techniques.
And we know that in the endoscopic world, getting an early resolution to problems that
you might have in the colonoscopy or endoscopy are vital to survival.
And in cardiac cases, we know that, gosh, that's not something any of us want to put
off.
If we have an issue, we'd like to take care of it as soon as possible.
Well, one of the things I should point out to our listeners is that 21 states already
have this expanded scope of practice for advanced practice registered nurses, empowering them
to manage treatments and diagnose patients and more.
So VA's proposal is not brand new cutting edge sort of stuff.
It's following what 21 other states have done.
And really for the same purposes, the VA Undersecretary of Health, Dr. David Shulkin,
has issued statements indicating that he thinks that this would increase VA's capacity
to provide timely, efficient, and effective primary care services.
But there's a lot of criticism, Dr. Quintana.
The number of the American Medical Associations, the Association of American Society of Anesthesiologists,
all are kind of critical of this move forward by VA.
How do you look at that criticism?
I appreciate you bringing that up because I think it's important to recognize concerns
that people have.
And being able to discuss those openly and debate those as professionals is the way to
get that move forward.
From our side of the equation, that is from the advanced practice nurse and more specifically
the certified registered nurse, our job is to provide an excellent service to veterans,
whether families, their children.
And to achieve that, we evaluate ourselves and make a determination whether or not we
are up to par.
All our studies, all our information says absolutely.
And while we understand that sometimes it's hard, both positions, as I mentioned earlier,
for a while, it was only a physician that could take your blood pressure.
Today, Walmart can do it.
So while I understand their concerns and sometimes it's a little battle of like, are you overlapping
into my workplace, am I overlapping into your workplace, that the overarching message here
is, servicemen, veterans need our care.
And that really, it's a good time to put down those turf wars and start looking at how we
can better achieve access to services for those veterans so they are not as victims in this
situation.
From our perspective, we recognize their concerns.
We have data to show that their concerns are essentially unfounded.
And they're not really providing any data to show anything otherwise.
So we're going to have to a little bit stick to our guns because we feel like at the end,
our mission is just what we want to achieve is access to services for veterans.
Let me take it from the broad category down to the individual because we've all seen,
we can talk about doctors doing good work, but we can get down to, hey, this is a bad
doctor.
How does it work with advanced practice nurses and CRNAs?
If somebody's not up to snuff or things in their life have interfered with them delivering
services, what are the licensures, disciplines, what are the steps?
Is there a protection there for the patient?
Absolutely.
What you should know is that in the hospital setting, in an ambulatory surgery setting,
whenever you are providing a service there, if you are having any kinds of problems or
you're not providing a service that is up to par, it's internally first handled by the
facility.
Facilities and peers will see that and they'll evaluate your service.
And in that, they'll make recommendations.
Either some kind of remediation, something to help you improve what you're doing and
you better at it and or they'll find that you are not capable of providing the service
and they'll ask you to move on.
In addition to that, if there's any issues beyond that, it's actually very similar to
the pattern the physicians follow and in some cases essentially the same.
It's just that the state board of medicine would not be handling it.
The state board of nursing would typically be handling the issue and they handle and
address those issues on a regular basis.
So the veterans can feel comfortable that while there are let's say the majority, 99%
of all of us out there functioning in healthcare world today in this evolution that is occurring,
provide an outstanding service.
Some folks have for whatever reason not been able to keep up or are not doing a good job
and we're readily addressing those issues and making sure that those folks don't stay
in healthcare if they're unable to improve.
We're talking to Dr. Juan Cantana who is the president of the American Association of Nurse
Anesthetists and we're talking about a proposal that VA has out to broaden and ensure that
advanced practice registered nurses have a full authority to practice to the full extent
like they do in 21 states.
Juan, a lot of things that come out of Washington are ultimately decided by politics maybe not
reason or common sense.
How do you see the politics moving forward on this?
Well, I think Jim that at this time the driving force has to be the need that veterans have
with regard to their healthcare services.
In that sense, I encourage all the veterans to you can certainly join our website at www.veteransaccesetocare.com
and fill out letters and say that you support this issue so that you can get access to services.
Many of you when you're a serviceman were in fact treated by nurse practitioners or
CRNAs and so I think that and I'm certainly hoping that will be the driving force here
that while we listen to and openly discuss the concerns of individuals, especially our
physician colleagues that at the end of the day we recognize the value of nursing today
is much broader than it was in the past and that we can achieve excellent, excellent care
for our veterans today so that they can avoid those waits and those times when my biggest
concern would be that something tragic would happen in that interim.
Well as we wrap up Juan, why don't you give that website again where folks can go if they'd
like to do more on this issue.
Absolutely.
That website again is www.veteransaccesetocare.com all lower case and when you go there it'll
ask you to take action and you click on that button and after that you have several choices
from which you can file out letters so that your message gets across to the individuals
to whom it makes a difference and it makes a difference to all of us but we have to get
that voice, that power behind it and make it loud and clear for all those folks in Washington
and at the VA that we want change and that APRNs can help us get care and we want that
care.
Well I want to thank Dr. Juan Quintana, President of the American Association of Nurse Anesthetists
for enlightening us today about advanced practice nurses and in particular about CRNAs, the
group that he leads.
I want to thank all of you for listening to Veterans Radio today.
I am Jim Fosso and it's been a pleasure to be your host and bring you this unique interview.
I'm a Veterans Disability Lawyer at Legal Help for Veterans and you can reach us at
800-6934800 or legalhelpforveterans.com.
You can follow Veterans Radio on Facebook and listen to our podcasts and internet radio
shows by going to www.veteransradio.net and until next time you are dismissed.
If you have a VA claim denied by the Board of Veterans Appeals, contact Legal Help for
Veterans at 1-800-6934800.
There are experts in handling cases before the U.S. Court of Appeals for Veterans Claims.
Your number again is 1-800-6934800.