VA's Specialized Nursing Care

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 January 2019, the most recent published account, more than 100,000 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 stateof-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 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.

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 blastinduced, 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 (TBI), 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. The ONS’ clinical nurse advisor for Polytrauma and SCI rehabilitation, Susan Pejoro, MSN, RN, GNP-BC, is located at the VA Palo Alto Health Care System.

The Palo Alto facility is one of 25 centers in the VA’s Spinal Cord Injuries and Disorders (SCI/D) System of Care, providing a coordinated lifelong continuum of services for veterans with spinal cord injury, from initial injury to death. The Palo Alto center has developed an upperextremity clinic to address an important issue: The fact that for many patients with paraplegia, their arms often receive less attention than other conditions secondary to SCI.

Pejoro, a gerontological nurse practitioner, 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, and 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 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 2012. At 15 workstations featuring eight computer screens apiece, critical care nurses and doctors monitor the status of more than 300 patients at 19 Veterans Affairs Medical Centers (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 patients’ 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, Maryland.

Alexis Carson, nurse case manager for the Wm. Jennings Bryan Dorn VA Medical Center, provides a medical screening at the Stand Down for Homelessness event in Columbia, South Carolina, November 2017. Nurse case managers are RNs who coordinate all aspects of the care of an individual patient, ensuring responsible utilization of services and resources.

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 fall 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.”

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.

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 provided outside the VA system. Because a possible consequence of this provision may be the movement of patients 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. RN primary care coordinators are critical in tracking down records, communicating with outside providers, and essentially performing case management to ensure the quality and continuity of veteran care.

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.

A veteran working on balance and strength at the Maryland Health Care System’s Baltimore VA Medical Center.

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 – behavioral health units and, later, geriatrics and extended care – 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 executives must have at least a master’s-level education; Bernstein earned his Master’s in Nursing Administration in 2003.

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 the 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 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. “Nursing research is vital to the practice of nursing and one of my passions has been participating in both qualitative and quantitative research,” she said. “Quantitative research allows to precisely measure the effect of a specific intervention: Does it help, harm, or have no effect on 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 experiences during the process. “First and foremost, I think it’s important for nursing as a profession to have a strong evidence base to support our practice,” said Ballard-Hernandez, “and second, we need to be able to translate that evidence base to those who are practicing at the bedside.”

More than 7,100 RNs in the VA health care system are advanced practice registered nurses (APRNs, holding at least a master’s-level degree, and 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 medications. 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:

1. 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 cover their services, but VA care is evolving to accommodate changing demographics.

2. 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 in both primary care and specialty oncology care. 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.” Engstrom performed data collection for several studies and also conducted her own, as a primary or co-primary investigator; her research expertise led to an appointment to an institutional review board at one of the VA’s university affiliates.

The focus of the CNS’ 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.

3. 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.

4. 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, Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, advanced practice registered nurse (APRN) program manager for ONS, was a primary care NP working in what’s now the George E. Wahlen VAMC. Over the years, as the hospital added specialty care services, she and other primary care NPs were moved out to community-based outpatient clinics 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. According to the VHA’s Office of Geriatrics and Extended Care Services, VA nurse practitioners dedicated the equivalent of more than 531 NPs working full-time to provide care to veterans in their homes, resulting in a national average cost savings of $7,936 per veteran.

NPs are poised to play a critical role in a modernization effort now underway within VHA: the expansion of RN-staffed call centers, which often functioned as referral services, into clinical contact centers where veterans can, to the maximum extent possible, have their health care needs met during their first contact with the VHA system. Storm Morgan, MSN, MBA, RN, ONS’ clinical program manager for Ambulatory and Virtual Care, explained that the goal of transforming these centers is to expand veterans’ access to convenient, highquality care. “We’ve had call centers in VHA,” she said, “but we’ve never had, to any extent, providers who could diagnose and treat on the phone. We would have to determine what the patient needed and send them where they needed to go to get that care.”

The new clinical contact centers will be staffed with more providers – nurse practitioners and physicians who can diagnose, treat, and prescribe – and will combine web, video, chat, and telephone capabilities to enable “first-contact resolution” of veterans’ health issues when possible. “We’re really trying to address patients’ needs when they call in,” said Morgan, “and not send them to other people to have their needs met.”

Many nurse practitioners in the VHA specialize or subspecialize. In Palo Alto, Susan Pejoro is a certified gerontological NP. Both she and Ballard-Hernandez, who runs the cardiac clinic at the Long Beach VA, serve as clinical nurse advisors in ONS’ 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 another cardiology NP, a case manager, a licensed vocational nurse, and a scheduler. A lot of work and study went into Ballard-Hernandez’s specialty and her more recent focus on general cardiology and heart failure; 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. Afterward, she completed an extensive post-graduate acute care NP program with a clinical focus in cardiology, and went on to earn 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 participate in research.”

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. Twentythree 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 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 ONS, but she and her team 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 the 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 needed to review and co-sign my work and treatment plan. But really it was a waste of valuable resources, because you’re paying a highly trained cardiologist to sit and oversee something that my education and training have prepared me to do. As NPs, our training focuses on health promotion, disease prevention, and improving health behaviors through patient education.” 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 that I need additional resources or a second opinion, our cardiologists are readily 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 served in the U.S. Marine Corps, VA nursing has always felt more like a calling than a job. “I’ve 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 and care for veterans.”