It’s the nation’s largest integrated health care system, so it’s no surprise that the Veterans Health Administration (VHA) is also the largest employer of nurses in the United States: In July 2018, the most recent published account, more than 95,787 nursing personnel delivered care to veterans at more than 1,250 health care facilities in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Philippines. Today, more than 9 million veterans are enrolled in the VHA system, and, in 2018, alone the system handled 58 million appointments.
The Department of Veterans Affairs (VA) nurses provide state-of-the-art, cost-effective nursing care to patients and families. It’s a common misconception that VA patients are predominantly older veterans, and that VA nurses spend most of their time delivering geriatric care. Older patients represent a significant percentage of the VA’s patient population, and many nurses have built careers in gerontology and geriatric care, but the veteran population receiving VA care is increasingly diverse and dynamic. As younger veterans from the conflicts in Iraq and Afghanistan have enrolled in VA health care, they have introduced unprecedented diversity – in ethnicity, culture, and gender – to the VA patient population, and nursing practice continues to evolve and accommodate these differences.
VA nursing services, administered chiefly through the VHA’s Office of Nursing Services (ONS), encompass patient care, clinical practice, education, research, and administration. VA nurses work in every role and setting imaginable: medical, surgical psychiatric, intensive care, dialysis, oncology, physical therapy, spinal cord injury, hospice, blind rehabilitation, geriatric, cardiology, organ transplant, nephrology, orthopedics, and other units. They provide a full continuum of care, from acute to primary and extended care, and they serve in medical centers, outpatient clinics, nursing homes, and home-based primary care.
Registered nurses (RNs) comprise the largest segment of health care employees in the VHA. A registered nurse holds, at minimum, a nursing diploma or Associate Degree in Nursing, has passed the National Council Licensure Examination for Registered Nurses (NCLEX-RN), and met all other applicable (state) licensing requirements. Most RNs are encouraged to go beyond minimal education requirements to earn a Bachelor of Science in Nursing (BSN) degree as a path to licensure, and to lay the groundwork for expanding their expertise after licensure.
More than 61,500 RNs serve in the VHA system, leaders or members of health care teams working to provide high-quality care and enable patients to optimize their own health. VHA RNs typically serve in four distinct – though not mutually exclusive – career paths:
While many RNs are generalists, others, particularly in the VHA, become interested in gaining expertise in a nursing specialization. There are literally dozens of clinical specializations available to RNs, knowledge and skills concentrated in a workplace setting (i.e, ambulatory care nurse), body system (pulmonary care nurse), patient population (geriatric nurse), or medical condition (oncology nurse). To gain recognition as a specialized nurse professional, RNs typically need to undergo further experience, clinical practice, and education and training in their specialized fields.
The VA typically requires RNs to become certified in their specialty area before they work with patients. When Alan Bernstein, MS, RN, the ONS’ deputy chief nursing officer, was a student nurse in the mid-1990s, for example, his first student nursing experience was spent in the medical-surgical unit of a hospital. After graduating he began his nursing career in with the VA, served two years as a medical-surgical RN, and then applied for a position in the intensive care unit (ICU). He was accepted and underwent a rigorous course of training and education.
“We went to ICU classes before we ever went on the floor and touched a patient,” said Bernstein. “We spent almost two months in a classroom in VA, learning all of the nuances of ICU patient care. Then when I came out of that class, there were tests and exams I had to take that were way more intense than what we had in nursing school, concentrating on the intensive care patient.” After passing these exams, Bernstein worked under the supervision of a nurse preceptor – a mentor assigned to help develop new staff nurses – for three or four months before he practiced independently in the ICU.
VA RNs often move from one specialty to another, Bernstein said, and the intensity of this professional apprenticeship, or of its component parts, varies. “If I’d gone from med-surg to the operating room,” he said, “I would have some classroom instruction that would teach me about all the instrumentation in the process of sterile technique. And I would have to be signed off on those competencies. And then my preceptor experience would probably be longer than it was in ICU.”
While VHA nurses practice every area of specialized care found in private-sector facilities, some roles and settings have emerged that are, if not unique to the VHA, areas of unusual emphasis. When a growing number of veterans began returning from Iraq and Afghanistan with polytrauma – multiple injuries, often blast-induced, that affected more than one part of the body – the VA ramped up its Polytrauma/TBI System of Care to help treat and rehabilitate veterans suffering from injuries including traumatic brain injury, spinal cord injury (SCI), limb loss, fractures, and burns. As the Iraq and Afghanistan conflicts have wound down, the focus among VA’s polytrauma nurses has shifted from acute care to rehabilitation.
VA’s Spinal Cord Injuries and Disorders (SCI/D) System of Care provides a coordinated lifelong continuum of services for veterans with spinal cord injury, from initial injury to death, through 25 centers and 130 affiliated clinics throughout the country. One of the 25 centers, at the VA Palo Alto Health Care System, has developed an upper-extremity clinic to address and important issue – the fact that for many patients with paraplegia, their arms often receive less attention than other conditions secondary to SCI.
Susan Pejoro, RN, MSN, GNP-BC, a gerontological nurse practitioner who works with patients at the center, pointed out that pushing oneself around in a wheelchair, often for decades, can be hard on the arms. Patients at the clinic often suffer injuries, misalignments, pinched nerves, and tendons from overuse of their upper limbs, and a Palo Alto team has organized to address these issues. “We work with a hand surgeon and occupational therapist, a physical therapist, a resident, and other nursing staff,” Pejoro said. Patients who visit the center for a well-check are examined closely for problems in the shoulders, arms, elbows and hands, and offered either a number of preventive corrections or, if they may be warranted, surgical options to improve function.
Because the Palo Alto Center serves patients in an integrated service network (VISN) that reaches from Las Vegas to the Philippines, Pejoro often relies on teleconferencing for an initial check-in. “I’ll set up a telemedicine appointment,” she said, “and say: ‘Hey, you’re coming in for your annual checkup, so let’s take a look at your hands and your arms and tell me what’s going on.’ And we can decide whether we need to have the full team involved.”
Telemedicine technologies allow VHA providers and nurses to accommodate two circumstances common to all large health care systems – but particularly to the nation’s largest. First, the system is mandated to meet the health care needs of 9 million veterans, many of whom live far from the nearest VA facility. Second, the need for expertise throughout the system is dynamic, with lulls and spikes in demand for certain kinds of care and service. An ICU at a VA medical center might find itself suddenly overwhelmed, for example, by an influx of patients needing critical care.
To enable a wider reach for VHA’s critical care expertise, the Cincinnati VA Medical Center established the Tele-ICU in 2011. At 15 workstations featuring eight computer screens apiece, critical care nurses and doctors monitor the status of more than 300 patients at 19 VAMCs and 10 emergency rooms, in an area reaching from Oklahoma to Maine. The screens feature real-time video streams from patient rooms, as well as feeds from equipment monitoring patient’s vitals, said Michael Torok, RN, the Tele-ICU operations manager. “We’re actually streaming those waveforms here in Cincinnati,” he said. “The patient could be in Charleston, South Carolina, in the medical intensive care unit, and our nurses are seeing in real time that patient’s waveforms here in Cincinnati.” Nurses at the workstations are aided by computer software that performs a kind of triage, sifting through patient records and data and flagging when patients may need special attention. A shift at the Tele-ICU is staffed by about seven to eight nurses – individual nurses at the center average 19 years’ experience in critical care – and a physician, and at night, includes a second provider, often an acute care nurse practitioner.
Tele-ICU expertise is meant to augment rather than replace the service of bedside teams, Torok said. For example, if a resident on staff at the ICU in Muskogee, Oklahoma, needs to insert a breathing tube into a patient, a physician and critical care nurse in Cincinnati can assist: the Tele-ICU physician can help guide the insertion of the tube and the ventilator setting, while the Tele-ICU nurse can put in orders for chest X-rays, blood gases, and other lab tests, freeing up the bedside nurse to tend to the patient. “The bedside team could be doing all the hands-on things that need to be done,” said Torok, “while the Tele-ICU critical care team is offloading some of the administrative work, as well as assisting with some of the clinical decision-making going on in the room.” About 40 nurses work shifts at the Tele-ICU in Cincinnati, and the center recently opened a satellite hub in Baltimore.
Another effort to supplement VHA care, the Interim Staffing Program (ISP), was established in 2013. Through the ISP, a pool of talented physicians, nurse practitioners, nurses and other care providers offer temporary staffing assistance to VA health care facilities. Within the ISP, 97 registered nurses comprise the VA Travel Nurse Corps, meeting the needs of facilities throughout the United States. According to Tyeasa Jones, RN, BSN-MSN, acting nurse director for the corps, VA’s travel nurses have served in nearly every imaginable capacity, including clinical care, home-based primary care, education, management, and quality control. Travel Corps nurses also play a key role in disaster response; in the fall of 2017, for example, after southeast Texas was devastated by Hurricane Harvey, VA travel nurses served with mobile medical units formed to provide health care in Houston and Beaumont. VA’s travel nurses, said Jones, “love to move about. They like the adventure of it. They are adaptable. They are inquisitive, resourceful, and creative. There’s not an area, I believe, within the VA where our nurses have not stood in to assist facilities whenever they have the need.”
Supporting and Directing
As health care delivery within the VHA has become more complex, technologically advanced and dynamic, coordination, and oversight of nursing care has become a critical role on both the micro and macro levels, even among the most basic units of care. For example, VA primary care nurses, in addition to providing clinical care to patients through interdisciplinary Patient Aligned Care Teams (PACTs), increasingly play a role in care coordination: facilitating the integration of services among team members and with other affiliated providers, including private-sector contractors.
According to Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, advanced practice registered nurse (APRN) program manager for ONS, care coordination has become an even more crucial role since last year’s passage of the VA MISSION Act, a law that allows for more VA primary care to be privatized. When patients move back and forth between providers in the private sector and the VA, it’s crucial that both sides are aware of, and coordinating, what’s happening in both settings. “So those RN care coordinators in primary care are really critical,” said Jensen, “because they do all of the tracking down of the records, calling the outside providers these veterans are seeing, and really performing case management. With the MISSION Act and more people being seen on the outside, it’s even more critical now.”
In the 1990s, a nursing role emerged to involve highly skilled nurses in improving the quality of nursing services: the clinical nurse leader (CNL). A CNL is a master’s-prepared nurse who tracks and documents quality measures in a microsystem – a unit – and educates and guides nursing staff in maintaining or improving them. CNLs communicate, plan, and implement care directly with other clinicians. They are generalists whose roles are highly variable, depending on setting and circumstances. “The ideal scenario is to have one on every patient care unit,” said Bernstein. “And their responsibility on the unit is to oversee the clinical care of all of the patients, to ensure that the front-line nursing staff have the skills and the knowledge to care for the patients as they come in and out of that particular unit.” CNLs may be involved in care planning for a particular patient, or in teaching other nursing staff how to plan care, or in educating staff about a new condition or circumstance.
As Bernstein points out, CNLs, like care coordinators, play more of a supportive role than a true supervisory or administrative role. They help other nurses and health care team members do their jobs better, but they don’t have the authority or mandate to do true administrative tasks: directing, hiring, firing, scheduling and budgeting. “They really are adjuncts to the administrative staff,” he said, “in the sense that they oversee clinical practice and make sure the staff on the unit can care for all the patients that come in and out of that unit.”
Bernstein’s own nursing career has been a march through the echelons of what are more commonly recognized as administrative positions – supervisors or managers who provide advanced leadership in resource allocation and evaluation. At the Pittsburgh VA Medical Center, he was nurse manager for a surgical unit. He moved on to become a nursing program leader (known in other facilities as an associate chief nurse), responsible for overseeing nursing services within a section of similar units – the medical-surgical units – at the medical center. In 2012, he became nurse executive for the second-largest health care system in the VA, the VA North Texas Health Care System, where he oversaw all the administrative and clinical aspects of nursing care for the entire nursing enterprise: 1,700 nurses and sterile processing personnel. Program leaders and nursing executive must have at least a master’s-level education; Bernstein earned his master’s in nursing administration in 2003.
Consultative Nursing Roles
Many VA nurses work to improve nursing care by examining processes and sharing knowledge with other personnel. An infection control nurse, for example, develops expertise in preventing the spread of infectious agents, such as bacteria and viruses, in VHA environments. These nursing professionals keep other medical staff up to date on proper sanitation practices; analyze infection data and share findings with other professionals; teach staff how to prevent and control outbreaks; and often work with scientists and doctors to study infectious agents and new treatments for illnesses.
Another important consultative role in VHA is the public or community health nurse, who often works beyond the scope of clinical care to guide veteran patients to necessary social or medical services, or to educate veteran communities about ways to reduce the likelihood of certain diseases or disorders.
The VHA prides itself on delivering evidence-based clinical care, and ONS has developed its own curriculum as a resource for those developing or teaching evidence-based practice in clinical settings. VA nurses work to develop and disseminate this evidence in several roles, including:
- Nurse Education. Nurse educators – RNs with advanced nursing degrees that allow them to teach at colleges and universities – serve as faculty members at both nursing schools and teaching hospitals, transferring their knowledge, experience and skills to nursing students. Within the VA, this knowledge is often imparted through education programs that use distance-learning technology to provide learning nationwide, to both students and nurses.
- Nursing Informatics. A rapidly growing field in health care, nursing informatics combines the art and science of nursing with the field of information management and computer analytics. Nurse informaticists develop and evaluate the tools and processes used by nurses and nurse administrators, such as electronic health records and communications systems, and they analyze information systems data to improve nursing services and reduce errors. Working behind the scenes, nurse informaticists focus on patient care, enabling nurses to do their tasks with advanced technology that improves patient outcomes. In 2010, the VHA, recognizing the importance of this emerging field, established a new Office of Informatics and Analytics (OIA) to consolidate all nursing informatics activities into a single national program.
- Nursing Research. With or without the support of VA funding, and often in partnership with academic affiliates, VA nurse researchers study aspects of health, illness and health care and look for ways to improve health and health care outcomes. Jennifer Ballard-Hernandez, DNP, AG/ACNP-BC, FNP-BC, GNP-BC, CVNP-BC, CCRN, CHFN, AACC, FAHA, FAANP, a nurse practitioner who specializes in cardiology at the VA Long Beach Healthcare System, has published research in several peer-reviewed journals and has lectured nationally to professional organizations on topics including heart failure, care transitions, and cardiac stress testing.
Like most graduates of nursing doctoral programs, Ballard-Hernandez received extensive training in the conduct of nursing research. “One of my passions has been working at both qualitative and quantitative research,” she said. “Quantitative research is: If I give a treatment to a patient, does it help, harm, or do nothing for a patient? I’ve been involved in those types of clinical trials, and I’m currently involved in one right now, looking at a new medicine for treating heart failure.” She’s also been involved in qualitative research: delivering new training and education programs to nurses themselves and then evaluating their effectiveness. “I think it’s important, number one, for nursing as a profession to have a good evidence base,” said Ballard-Hernandez, “and second, to be able to translate that evidence base to those who use it at the bedside.”
Advanced Practice Nursing
More than 7,100 RNs in the VA health care system are APRNs, holding at least a master’s-level degree (many ARPNs go on to earn doctorates) and exercising greater professional autonomy. By education and certification, APRNs are prepared to assess, diagnose and manage patient problems, order tests, and prescribe +s. They may authorize or delegate therapeutic methods to supporting personnel, and often confer with outside disciplines and offer referrals to other professionals or agencies.
There are four defined APRN roles:
Certified Nurse Midwife (CNM). CNMs handle the gynecologic and primary health care of women from adolescence through menopause. Until recently – because so few U.S. veterans were women of child-bearing age – the VA did not employ CNMs or even cover their services. Its care is evolving, however, to accommodate changing demographics; last year, the VHA hired its first CNM to serve women veterans at the Baltimore VA Medical Center.
Clinical Nurse Specialist (CNS). A CNS is an RN with a graduate degree in a specialized area of nursing practice, and occupies an important niche in VA Care, though the role is difficult to explain to non-nurses, who often confuse it with a Clinical Nurse Leader. The distinctions between the two are many, though they differ most significantly in expertise (CNLs are generalists; CNSs are specialists) and scope of practice (the CNL’s sphere of influence generally encompasses nursing practice and patients; while the CNS sphere can expand to include the entire health care system). CNSs generally work at this systems level to promote nursing excellence in their specialty areas.
Christine Engstrom, PhD, CRNP, AOCN, FAANP, the ONS’ director of clinical practice, was an oncology CNS in VA for 10 years before becoming a nurse practitioner. She described the CNS as “a more global role. I would do many different things in that sphere of oncology, working across different systems – our VISNs around the country, or even within the Maryland health care system, those hospitals working on policies for chemotherapy safety, standard operating procedures and education. I also did research.” The primary focus of the CNS’s role, then, is to ensure nurses in their specialty area have the knowledge, skills, policies, procedures, and equipment they need to provide optimal care. There are currently just over 300 CNSs at work in the VHA.
Certified Registered Nurse Anesthetist (CRNA). CRNAs work in collaboration with surgeons, anesthesiologists and other professionals to ensure the safe administration of anesthesia in VHA facilities. CRNA responsibilities include administering anesthesia during surgical, diagnostic, and therapeutic procedures; providing care before, during and after anesthesia; monitoring patients during medical procedures; examining patient histories to ensure safe provision of anesthesia or pain management; and discussing any contraindications or side effects with patients. The nearly 1,000 CRNAs who provide care within the VHA system are generally found at hospitals.
Certified Nurse Practitioner (NP). NPs are licensed, autonomous clinicians focused on managing health conditions and preventing disease. NPs comprise the vast majority – more than 5,800 – of VA’s advanced practice nurses, and about half of them serve in either primary care or women’s health. When she began her nursing career with the VA Salt Lake City Health Care System in the late 1990s, Jensen was a primary care NP working in what’s now the George E. Wahlen VAMC, in Salt Lake City. Over the years, as the hospital added specialty care services, she and other primary care NPs were moved out to Community-Based Outpatient Clinics (CBOCs) and saw veterans in and near their own communities.
Many of the VHA’s NPs serve in the Home-Based Primary Care (HBPC) program, visiting veterans in their homes to provide diagnosis, care and treatment. Each one of the 147 regional health care systems in the VHA operates an HBPC program, accounting for a considerable number of NPs. (insert HBPC numbers here). Since passage of the MISSION Act and its provisions for expanding access to care … (insert numbers on NPs working at Clinical Contact Centers).
Many nurse practitioners in the VHA specialize or sub-specialize. In Palo Alto, Susan Pejoro is a certified gerontological NP. Both she and Jennifer Ballard-Hernandez, who runs the cardiac clinic at the Long Beach VA, serve as Clinical Nurse Advisors in ONS’s nationwide Clinical Practice Program, developed to support and bring expertise to nursing practice at the point of care – Pejoro for Polytrauma; Ballard-Hernandez for Cardiovascular care.
Today Ballard-Hernandez divides her time between this role and her oversight of the Long Beach cardiac clinic, where she directs the work of a case manager, another cardiology NP, and a licensed vocational nurse who serves as a scheduler and delivers care. A lot of work and study went into Ballard-Hernandez’s specialty and her more recent focus on heart failure and transplant surgery; while working toward her master’s degree and RN certification she was able to spend an additional 500 hours of training with a cardiologist, beyond her minimum requirements. Afterwards, she completed an extensive post-graduate fellowship in cardiology and cardiovascular surgery before earning her Doctor of Nursing Practice degree.
“The great thing about the VA,” said Ballard-Hernandez, “is there are a lot of opportunities and options for nurses to excel and have professional growth. And there are a lot of nurses, like me, who practice clinically and also do research.”
Widening the Scope of Practice for APRNs
An issue that remains unresolved for many APRNs in the United States is that their scope of practice – the services a qualified health professional is deemed competent to perform and permitted to undertake – varies from state to state. Twenty-three states, following the model recommended by the National Academy of Medicine and the National Council of State Boards of Nursing, currently grant “full practice” authority to nurse practitioners, meaning they can provide care and prescribe treatments and medications without requiring the direct supervision of a physician. A considerable number of states, including California, Texas, and Florida, remain “restricted practice” jurisdictions, where state practice and licensure laws constrain the ability of NPs to engage in at least one element of practice, requiring career-long supervision, delegation or team management in order for a nurse practitioner to provide care.
In a nationwide health care system such as the VHA, these inconsistencies resulted in an inefficient use of its resources and presented considerable challenges to maintaining veterans’ access to nursing expertise. Requiring a physician’s signature for every NP decision, said Kaye Jensen, tended to bog things down. “It was really taking up time,” she said. In some states, NPs were required to attend board-mandated collaboration sessions, which kept them away from patients. “People were cancelling hours in their clinics,” Jensen said, “just to meet their state requirements, and on those days, we weren’t seeing veterans we could have been seeing.”
Jensen led a team of nurse practitioners who worked with the U.S. Department of Justice to determine that the VHA, as a federal system, could implement provider regulations that took precedence over those of the states. It took five years of work, in which Jensen was detailed to the VHA’s Office of Regulatory and Administrative Affairs, but she wrote the proposed rule change that was eventually adopted – for the most part, after receiving 223,000 public comments – by the VHA: On Dec. 14, 2016, the Department of Veterans Affairs published its rule granting veterans direct access to care by three of the four APRN roles in the VHA: nurse practitioners, certified nurse midwives, and clinical nurse specialists. In a press release accompanying the announcement, the department explained that “we do not have immediate and broad access challenges in the area of anesthesia care across the full VA health care system that require full practice authority for all certified registered nurse anesthetists.”
Jensen and other ONS leaders will continue to push for full practice authority for CRNAs within the VHA, but in the meantime the rule change has meant greater autonomy for other APRNs throughout country – which translates into more timely, comprehensive, focused care for veteran patients. In California, Ballard-Hernandez is working directly with patients and making administrative decisions about the Long Beach VA’s cardiac clinic. Before adoption of the new rule, she said, “I had to have a physician assigned to the clinic who sat while I would see patients, review my work, and say ‘yes’ or ‘no.’ But really it was a waste of resources, because you’re paying a highly paid cardiologist to sit and oversee something that my education, training and licensure have prepared me to do.” She now runs the clinic, fully and independently. “Now, that’s not to say we don’t still have a really interdisciplinary team approach,” she said. “If I feel I need additional resources, our cardiologists are available to consult.”
The VA’s trust in her professional judgment is one of the many reasons Ballard-Hernandez decided, years ago, to move from the private sector into caring for veterans. For Ballard-Hernandez, whose brother serves in the U.S. Marine Corps, VA nursing has always felt more like a calling than a job. “I’d worked in the private sector for a good number of years,” she said, “and felt that it was time for me to give back. So, when a position opened up, I applied and was fortunate enough to be accepted. I’ve never looked back, and it’s been one of the best career decisions I’ve ever made. I’m very, very lucky to work for veterans and take care of them.”