Why title protection matters

What are veterinary techs known as? These names are in use or in debate. Titles matter and continue to be an issue within the industry. The idea of title change for credentialed veterinary technicians (CrVT) in the United States to “Registered Veterinary Nurse,” or the simplified, “veterinary nurse,” has been around for decades. The Veterinary Nurse Initiative (VNI) was formed in 2016 to push this effort. Initially co-chaired by Kenichiro Yagi and Heather Prendergast, with legal counsel from the Animal Policy Group, the VNI is supported by the National Association of Veterinary Technicians in America (NAVTA).1 The VNI has many notable goals, with title change being only one. In this article, we will reflect upon the title change efforts to date and discuss the legal and ethical realities accompanying the push for change. We will specifically focus on the usage of proposed titles before they have been codified in state Veterinary Practice Acts. (Note: The purpose of this article is not to discuss the merits of different, potential titles for our profession. Indeed, some co-authors feel “veterinary nurse” is an appropriate title. Others think we should strengthen the already established title. However, all co-authors agree the current use of another profession’s long-held (and long-protected) title without legislative support is inappropriate.) Why a title change at all? The justification behind title change efforts is multi-faceted. Title change is an effort to simplify public education and understanding of what the CrVT’s role on the veterinary healthcare team is. Some proponents believe a title change will translate into better pay for CrVTs. Others believe a new title will end the pervasive title misuse currently occurring at all levels within the veterinary profession. Already it is commonplace for individuals without credentials, or essentially anyone who touches an animal, to be referred to as “veterinary technicians,” “techs,” “VTs,” or the like. Long before the VNI, rampant title appropriation was evident with individuals and hospitals calling anyone performing patient care “nurse,” with or without the “veterinary” qualifier. The publicity around the proposed new title has only exacerbated this issue, leading to more confusion both within our profession and the public. The VNI failed to provide guidelines on how this title should or should not be used pending widespread legal acceptance. Since 2017, there have been eight attempts to introduce and pass legislation to amend veterinary practice acts to change or include the title “veterinary nurse” (OH, TN, OK, IN, GA, ME, NC, WV). These efforts have failed due to strong opposition from human nursing associations, CrVT opposition, legislative inaction, or a combination. It is noteworthy these states were chosen because they were all deemed to be ones with the least opposition to a title change attempt. While legislative efforts have failed or stalled, a few states attempted rule changes recognizing the term “veterinary nurse,” which supporters have indicated is part of their overall strategy of normalizing the use of the title to “grease the skids” toward legislative change. For instance, in New Hampshire, a proposal was submitted in August 2022 to recognize the term “veterinary nurse.” The NH Nurses Association filed a letter of opposition, and the rules have not been changed as of January 2023. Rules set forth by state veterinary medical boards or other state and local agencies/committees are not laws; rules are more flexible. Rule changes have been necessitated by some veterinary technology schools adopting “nursing” or “nurse” in their degree name, program title, and general terminology. The addition of “veterinary nurse” in the rules section of veterinary board governance should not be construed to encourage, protect, or promote the use—it is not an actual move toward title change, though it is a strategy to make the title appear more legitimate. The American Veterinary Medical Association (AVMA) has remained silent concerning a title change initiative, acknowledging the VNI, but specifically voting to remain neutral on the topic in 2018.2 The following sections detail where we believe the VNI and veterinary professionals have gone wrong. Entitlement Comparisons of what veterinary technicians do versus human nurses show job requirements of human nurses and veterinary technicians are often similar in various settings. However, “nurse” is a legally defined title with strict regulations surrounding the education, licensing, and regulation required of people seeking to use the title. Although the job of a veterinary technician can appear similar to the position of a nurse, it does not mean a veterinary technician can assume the title and role of a nurse. It would be akin to a veterinary technician calling themselves a veterinarian because they perform similar tasks despite not having the requisite education and licensing. Unfortunately, NAVTA does not appear to grasp the problematic nature of using a title out of legal context. At the Vermont Veterinary Technician Association’s 2022 membership meeting, Ed Carlson, the 2021 NAVTA president, said: “There was a letter that has come to all–as far as l can tell, all–at least some of the other institutions that changed their degree to veterinary nursing from the nursing association and was basically a cease-and-desist letter from,* again, the nursing association. Not from an attorney. None of them responded to it that received it to the best of my knowledge, nothing has ever happened beyond that. So, our thought is that yes, the human nursing association, not necessarily human nurses because there are many human nurses who once they understand what we do don’t have an objection to it, but the Association feels like they don’t want us to use that title. But I don’t feel that because another profession doesn’t want us to do something–that’s not a good reason not to do it. Right? And so, yes, the nursing association has powerful lobbyists–we would need powerful lobbyists too perhaps, but there are already states that are doing things that are opening the way like New Hampshire.” (Authors’ note: *We were unable to confirm who the letters came from or who received the alleged letters.) When asked about the cease-and-desist letters and similar communications, the American Nurses Association (ANA) said they are encouraging state chapters and associations to stay vigilant while also vowing to continue opposing title change initiatives. While researching the incident of a college changing its name based on receiving one of these letters, we reached out to Tricia Gorham, the chair of St. Petersburg College Veterinary Technology Program in November of 2022. She shared in 2019 the program changed the title of its veterinary technology program to “Veterinary Nursing.” After opposition from the human nursing association, including a warning of potential legal action, the program reversed the decision. Incongruously, Mr. Carlson’s statement of “I don’t feel that because another profession doesn’t want us to do something- that’s not a good reason not to do it. Right?” contradicts what NAVTA did in 2016 by having a NAVTA board member speak at the California Veterinary Medical Board hearing asking human physical therapists to stop infringing on the practice of veterinary medicine. Opposition from the ANA and state nursing associations From the outset, the title change effort has faced a steep uphill battle, primarily from the American Nurses Association (ANA) and state nursing associations. In 2020, a registered nurse member of the ANA filed a complaint with the Association after attending the VMX conference as a guest and seeing the widespread use of “Nurse” in the veterinary profession. In response, the ANA filed a complaint with the Federal Trade Commission (FTC) in December 2020 stating in part: “The American Nurses Association represents the interests of four million registered nurses in the United States. Our nation’s nurses are our heroes; we honor and support their continued dedication and resilience while on the front lines fighting the Coronavirus (COVID-19) pandemic. As an advocate for our nation’s nurses, the American Nurses Association requests an investigation of deceptive practices by schools of veterinary technology advertising a terminal degree in veterinary nursing and the ability of graduates to refer to themselves as a nurse upon completion as well as other organizations actively using the term veterinary nurse, including Today’s Veterinary Nurse. These organizations use of the term nurse is deceptive, misleading, unfair, and counter to local laws. […] For more than 100 years, the nursing community has consistently and actively taken efforts to promote and protect the title of nurse from unauthorized use by people in various vocations and has specifically been active in protecting the title from attempts at use by those who care for animals, rather than people. […] ANA and its state affiliates have persistently worked to protect the title of nursing. We have also expressed our opposition to NAVTA.[…]” The letter included the names of veterinary technology programs, veterinary publications, and conference organizations that use the term “nurse” inappropriately and illegally, in their opinion. As of the publication date, we are unable to confirm what, if any, action has been taken by the FTC. Opposition from credentialed veterinary technicians In 2020, a petition by CrVTs asking NAVTA to reconsider the title change portion of the VNI and to instead focus on title protection for the term “veterinary technician” garnered over 1,000 signatures. Although the petition was not formally submitted, NAVTA listened to the sentiment of it. In an article published by the Veterinary Information Network, Carlson wrote NAVTA was not initiating or funding lobbying efforts toward title change, but would continue supporting grassroots efforts. Mark Cushing, from Animal Policy Group, was also quoted in the article stating he no longer speaks on behalf of NAVTA. The article also notedthe VNI had raised $362,510, with $252,623 going towards lobbying and legislative strategists, and pointed out an updated figure was unavailable due to a “routine audit.” Updated figures have been requested but not provided.3 We reached out to Mr. Cushing with the following questions via email in November 2022: Authors’ question: I understand you have stepped away from NAVTA in assisting with [the VNI]? Can you expand on that, if comfortable? Cushing: The NAVTA initiative suspended operations a few years ago. Q: I am also curious why legislatively you think this didn’t seem to stick, or where those involved could have done better? Cushing: Legislation was poised to pass in Tennessee, Indiana, Ohio, and Georgia. Main problem was opposition and lobbying by state and national nursing associations, which were unwilling to tolerate any group using the title, “nurse” for no reasons other than power. Secondary problem was neutrality by AVMA and some state VMAs, which caused legislators to assume this didn’t matter to veterinarians. Some of the veterinarian neutrality and opposition stemmed from fears of having to pay people more if they were called nurses rather than veterinary technicians. Q: Finally, I am interested in your thoughts on why you feel “nurse,” even in title protected states (per the American Nurses Association), would still be something to reach for? Or has that time passed? Cushing: I doubt the politics have changed, so passage of legislation is unlikely. However, just as Purdue changed degrees from veterinary technology to veterinary nursing and no lawsuits were filed, I remain of the belief that practices, and the industry could simply start using the term veterinary nurse and nothing bad would happen. Most recently, multiple veterinarians in Texas were reported to the Texas Board of Veterinary Medical Examiners for allegedly referring to their staff members as “nurse” or “veterinary nurse.” Both “nurse” and “licensed veterinary technician” are protected in Texas, one under laws relating to human nursing and the other under statutes that relate to veterinary medicine. In most states, similar laws can lead to legal repercussions for veterinarians or staff who improperly use the terms “nurse” or “veterinary technician.” In Utah and Colorado, the attempts to introduce “veterinary nurse” were unsuccessful (in 2020 and 2022, respectively). Since then, both states have passed legislation recognizing credentialed veterinary technicians, notably omitting the noun, “nurse,” despite lobbying attempts to include it. NAVTA appears to endorse this trend. In a March 2022 article, AVMA News reported, “[2022 NAVTA President Ashli Selke] also wants to see more states not only restrict the use of the title of veterinary technician but also penalize misuse and ensure licensed technicians know how to report misuse.”4 On the other hand, despite new statutes and public sentiment, NAVTA continues to muddy the waters of title use, often with the organization and its leadership issuing contradicting statements. For example, in a December 2021 statement still on their website and reshared again in January 2022 on the VNI Facebook group, NAVTA stated: “‘NAVTA recognizes that a growing number of employers are advertising positions for veterinary nurses,” said NAVTA President Ed Carlson, CVT, VTS (Nutrition). ‘NAVTA only supports the use of the job title ‘Veterinary Nurse’ by credentialed Veterinary Technicians – those with a valid CVT, LVT, LVMT, or RVT designation. NAVTA urges that employers require credentials as a Veterinary Technician for those in Veterinary Nurse positions.’”5 In a VPN Plus+article, NAVTA’s 2022 president, Ashli Selke, wrote: “The National Association of Veterinary Technicians in America (NAVTA) recognizes a growing number of employers are using the title ‘veterinary nurse’ to be synonymous with ‘veterinary technician.’ NAVTA supports and encourages this movement.”6 And in a March 2022 AVMA article,4 Selke lamented: “If we’re not valuing a title, we’re not giving anyone an incentive to go to school or to move forward” The March/April 2022 issue of the NAVTA Journal included the “NAVTA Title Protection Survey and Report Findings.”7 This report describes title protection as one of the most important issues to many in the field. The findings were compiled by the VNI Task Force after reading and interpreting each state’s veterinary practice acts. In March of 2022, the authors of this article conducted their own review. All 50 veterinary state medical boards or acting authorities were contacted, including those in Puerto Rico and Washington, DC, [via email in March, 2022]. We received a total of 33 replies. Multiple boards found differences in interpretation and intent compared to NAVTA’s report. We asked the following two questions: “Does the Board have an official statement or opinion on the use of “veterinary nurse” in your state?” “If your state also has title protection for the term “nurse” in the human medical context, is the Board inclined to enforce title protection for those using “nurse” in the veterinary context with or without the prefix [qualifier] “veterinary”?” Only one state, Vermont, replied in favor of the title change. Six other states (GA, WV, NJ, KS, NC, WI) have no opinion, could not give an opinion, or are neutral, but stressed the human nursing board could take action. The remaining 26 states (CA, HI, NV, NY, TN, LA, MD, MI, NB, PA, UT, CO, MN, RI, WY, AZ, IA, KY, ME, MS, SC, VA, WA, OR, OH, NC) made clear reference to their veterinary practice acts stating “veterinary technician” (with the state’s specific modifier) should be the only title used by CrVTs, and inclusion of the word “nurse” could fall under the laws and regulations of the human nursing board where enforcement could be triggered. A few states that reviewed the NAVTA report disagreed with some of the categorizations the report mentioned of certain states having “no” or “limited” title protection, stating they felt it was a misrepresentation of their practice act and they indeed have full title protection. Some boards offered the following statements to explain their opposition to the term nurse: Kentucky: “The Kentucky Board of Nursing has indicated that they will uphold title protections for the term “nurse” in human medicine, and will not allow the use of “nurse” in any other context. However, KBN has indicated they would make allowance in veterinary medicine should the term ALWAYS appear as “veterinary nurse.” The Kentucky Board of Veterinary Examiners (KVBE) has also spoken with the leadership of the Kentucky Veterinary Technician Association (KVTA). It is KBVE’s understanding that KVTA has surveyed their membership, and the majority do NOT support the “veterinary nurse” initiative.” – Michelle Shane, KBVE executive director Minnesota: “This Board does not support the use of the term, “veterinary nurse’” because the title “nurse” is legally protected in this state. The Board of Nursing concurs.” – Julia Wilson, DVM, MBVM executive director South Carolina: “The Board, on April 3, 2014, approved an Advisory Opinion, which ‘recommends and advises that its veterinary aides or other employees of a licensed veterinarian not use the term “nurse” to avoid possible confusion.” – Lesia Shannon Kudelka, communications director and ombudsman SC Department of Labor, Licensing and Regulation False comparisons Another argument often put forward by proponents of a title change is “many other countries” use “registered veterinary nurse (RVN)” and that title change would align us with the profession on a global basis. In the UK, RVNs have recently started their own campaign for title protection. However, in Australia, both “veterinary nurse” and “veterinary technician” are used to refer to credentialed members of the veterinary care team, with “veterinary technician” representing a higher level of education and testing. In Canada, RVT is a nationally recognized title (standing for both registered veterinary technician and registered veterinary technologist, depending on the province) with title protections. A public education campaign about the role of RVTs on the veterinary healthcare team accompanied the Canadian legislative success. Globally, there are few countries with veterinary support team members with similar skills, education, and licensing. Untested legal theory According to Carlson, 2021 NAVTA president, speaking at the Vermont Veterinary Technician Association meeting in 2022, “…there are individuals who are very vocal on social media in particular and showing up to some meetings like this that continue to tout that – there are many states where “nurse” is a protected title. That’s absolutely true if you’re working in human medicine, but title protection does not transfer from one profession to another. So, by having– by us working in the veterinary profession and having the qualifier in front of the term “nurse,” “veterinary nurse” it’s very obvious that is a different profession and would really–the legal standard for if this would be infringing upon title protection in any state, from every attorney that NAVTA has spoken with and various other groups have spoken with, has said that the real legal issue would be if whatever we were calling ourselves [nurse] could reasonably be misconstrued by the public as we were treating humans. And so, working in a veterinary hospital and having “veterinary nurse” as your title- none of them believe that would be the case Mr. Carlson is not an attorney and may misrepresent a better-defined legal theory; additionally, the initial attorney for the VNI no longer represents NAVTA or the VNI. There is also no public statement from a legal expert on this issue, nor is there any precedent set. Legal challenges may reach beyond just a title. In some states, title misuse is a consumer protection issue depending on the governing agency. Where the Department of State oversees professions, the misuse of titles can violate consumer protection, especially where a title is linked to specific educational and licensing requirements. Examples for two states are: New York: (2006) Section 6903 of Title VIII Education Law reads as follows:“No person shall use the title “nurse” or any other title or abbreviation that would represent to the public that a person is authorized to practice nursing unless the person is licensed or otherwise authorized under this article.” Texas: Section 1. Subchapter D, Chapter 301, Occupations Code Section 301.1606: “(4)(d) Unless the person holds a license under this chapter or as a vocational nurse under Chapter 302, a person may not use, in connection with the person’s name: (1) the title “nurse”; or (2) any other designation tending to imply that the person is licensed to provide nursing care.” When faced with opposition, some who defend the sustained use of the title “nurse” in the veterinary context also use the “nurse shark argument.” This argument attempts to confuse the issue and misinterprets state statutes by implying if “nurse” is truly protected, then calling a Ginglymostoma cirratum, a “nurse shark,” would be illegal. This is an absurd argument. Doctrines of legal interpretation focus on the “reasonable man” standard – no reasonable man would confuse a shark and a nurse. However, that same reasonable man could be confused by the distinctions between a nurse for humans and a veterinary nurse, especially with the inappropriate adoption of the term “nurse” in the veterinary industry, often unaccompanied by the “veterinary” modifier. Where do we go from here? There are currently four legal titles for a CrVT in the U.S: RVT, CVT, LVT, and LVMT. Adding a fifth term, RVN (or another form of veterinary nurse) would do little to alleviate confusion about what our profession does. And the use of a non-legal term further convolutes the issue. The authors understand the sentiment behind the title change, but the words are hollow without title protection. Veterinary professionals must reserve the title “veterinary technician,” “technician,” and “tech” for those who hold current RVT, CVT, LVT, or LVMT credentials. This also means referring to those without these credentials – regardless of their experience, skill, or the respect one may have for the individual – with their appropriate title of “veterinary assistant,” while supporting their efforts to achieve their credential. A December 2022 survey of NAVTA members showed significant support for title protection of “veterinary technician” even when asked against the title “veterinary nurse.”7 In closing, we remember the sentiments of current co-chair of the VNI, Kenichiro Yagi, and former co-chair, Heather Prendergast, expressed in 2019, in Today’s Veterinary Nurse: “There are not many things that demoralize credentialed veterinary technicians more than having their title applied to those who did not rightfully achieve it, and this unfortunately is highly prevalent among veterinary practices today.…Title protection language is put in place to prevent individuals from misrepresenting themselves as meeting qualifications without actually doing so.”8 We wholeheartedly agree and believe there are few things that demoralize other professionals than having their legally protected title co-opted. Stephen Niño Cital, RVT, SRA, RLAT, CVPP, VTS (LAM-Res. Anesthesia), is a lab manager and veterinary technician specialist at Stanford University. He is actively involved in the veterinary industry serving on multiple Boards and committees. More can be found about him at www.stephencital.com. Liz Hughston, MEd, RVT, VTS (ECC) (SAIM) is one of the few CrVTs in the U.S. who holds all four available veterinary technician credentials. She serves as president of the National Veterinary Professionals Union (www.natvpu.org) and works as a relief technician and trainer in California. Liza Rudolph, RVTg, VTS (CP-CF) (SAIM), is a veterinary technician specialist with more than 20 years of clinical experience. Her current role is program director for the Veterinary Technician Program at Rowan College of South Jersey. Andrea Pace, JD, MBE, CVT, VTS (ECC), is a veterinary technician specialist at a privately-owned small animal specialty practice in New Jersey. In addition to her interest in clinical education, she strives to use both her MS in Bioethics and her law degree to help others understand the non-medical aspects of our profession. References https://todaysveterinarynurse.com/news/the-veterinary-nurse-initiative-update/ https://www.avma.org/javma-news/2018-11-15/whats-name https://news.vin.com/default.aspx?pid=210&Id=10368401 https://avmajournals.avma.org/display/post/news/navta-calls-for-better-protection-of-veterinary-technician-title.xml https://navta.net/news/navta-the-job-title-of-veterinary-nurse-should-be-reserved-for-credentialed-technicians/ https://www.veterinarypracticenews.com/myvpnplus/vet-technicians-need-and-want-title-protection-why-so-inconsistent https://navta.net/news/navta-report-shows-title-protection-for-veterinary-technician-is-needed-and-desired-but-absent-and-misunderstood-in-most-states/ https://todaysveterinarynurse.com/wp-content/uploads/sites/3/2019/09/NAVTACorner_TVNFall2019.pdf

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Why title protection matters

A look at where we’ve been, where we’re going, and why it is still an issue.

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