V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K
VHA’S SPECIALIZED NURSING CARE By Craig Collins n 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
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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: CLINICAL NURSING 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. “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
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