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December 19, 2017

White House classifies clinical nurse specialists as RNs again—drawing pushback

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    The White House Office of Management and Budget (OMB) in its latest revision of the Standard Occupational Classification (SOC) System continues to classify clinical nurse specialists (CNSs) as RNs rather than as advanced practice registered nurses (APRNs)—a categorization that has drawn criticism from nursing organizations.

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    According to Health Leaders Media, CNSs undergo more education and training than do RNs, holding a master's degree or a doctorate in nursing and taking advanced classes in anatomy, physiology, pharmacy, and assessment. They are authorized to practice as independent providers with autonomous patient management and prescriptive authority.


    According to Health Leaders Media, when OMB which is within the executive office of the president—opened a second public comment period on the revised SOC system, the National Association of Clinical Nurse Specialists (NACNS) and several other nursing organizations asked OMB to classify CNSs as APRNs. However, OMB in the revised system continued to categorize CNSs as one of four types of RNs and limited APRNs to three types: nurse anesthetists, nurse midwives, and nurse practitioners.

    Writing in McKnight's Long-Term Care News, Lola Coke argued the decision runs counter to "the rest of the federal government" and other industry organizations. In the Balanced Budget Act of 1997, Congress recognized CNSs as APRNs and allowed them to have their services billed directly to CMS. And the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, formerly the Institute of Medicine, six years ago recommended in a report that all APRNs—including CNSs—be allowed to have full practice authority.

    Meanwhile, the Department of Veterans Affairs has proposed an amendment to its medical regulations that would allow all VA APRNs to have full practice authority, a category in which CNSs were included. And the National Council of State Boards of Nursing recognizes CNSs in its APRN Consensus Model.

    Why experts are calling for a change in classification

    According to Health Leaders Media, one reason experts say CNSs need to be categorized separately from RNs is for accurate data collection.

    For instance, Vince Holly, president of the NACNS Board of Directors, said CNSs' "skills and work are sufficiently distinct to reliably collect workforce data as an SOC detailed occupation." He added, "Lumping CNSs into the general RN category prevents federal researchers from accurately capturing health care workforce data. Incorrectly categorizing clinical nurse specialists skews the quality and utility of federal health care policy data because CNSs perform specialized advanced nursing tasks versus the generalist tasks of the RN."

    Coke added, "It prevents researchers, health care systems, and state and federal agencies from differentiating between CNS workforce data and RN workforce data, and comparing that to any other APRN data."

    In addition, while other groups' categorization of CNSs as APRNs "have more sway over APRNs' practice and reimbursement than OMB," HealthLeaders Media reports, OMB's classification could still be a "cause for concern." For instance, Coke noted that if state licensing and credentialing agencies adopt the SOC system of classification, "they may prohibit CNSs from practicing to the full extent of their skills, education and experience, even while allowing other types of APRNs to do so"—thus "den[ying] consumers positive outcomes that could be afforded through advanced CNS practice" (Thew, HealthLeaders Media, 12/5; Coke, McKnight's Long-Term Care News, 8/19).

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