Guest Columns

Clinical nurse specialists are APRNs and must be classified as such

Lola A. Coke
Lola A. Coke

The Standard Occupational Classification Policy Committee of the Office of Management and Budget recently revised the 2010 SOC system which classifies workers into 840 detailed occupations. The system is used by federal statistical agencies to collect, calculate and disseminate data. Unfortunately, in making those revisions the committee chose to again classify clinical nurse specialists as general registered nurses, when they are, in fact, one of four categories of advanced practice registered nurses.

The revised SOC system has seven broad categories classifying the nursing workforce. They include four types of general registered nurses and three types of APRN: nurse anesthetists, nurse midwives, and nurse practitioners. 

The fourth category of APRN, the CNS, is missing, and the SOC incorrectly classifies clinical nurse specialists as RNs and not as the specialized, advanced healthcare practitioners that they are.

 

This classification is not only incorrect, it's hugely problematic for clinical nurse specialists, their patients and our healthcare system, especially in long-term care.

For more than half a century clinical nurse specialists have been playing a central and unique role. They are a part of the healthcare leadership team and provide expert care to patients and their families, support nurses caring for patients at the bedside, help drive practice changes at their organizations, and ensure the use of best practices and evidence-based care to achieve the best possible patient outcomes.

As part of the team, these specialists work collaboratively with other healthcare professionals to deliver the highest quality care and develop quality initiatives that changes the face of health care. Their contributions to producing good healthcare outcomes must be identified and quantified accurately.

Not only does covering CNSs under the RN category make that impossible, but classifying CNSs as RNs ignores both the nature of CNSs' role and their extensive education in advanced nursing care, physiology, pharmacology, and physical assessment. An RN may hold either a bachelor's degree in nursing from a four-year institution or an associate's degree from a community college. Like other APRNs, CNSs must have at least a master's degree in nursing, and many have doctoral degrees. 

The graduate-level education CNSs receive provides them with discrete skills and  education. It goes beyond the RN role and they can perform a role that is quite distinct from RNs. In fact, many healthcare organizations that have nurses' unions exempt the CNS position from joining the union because the roles of a CNS and RN are so different.

Including CNSs into the general registered nurses category makes it impossible for nursing and healthcare researchers to accurately capture the data and statistics that represent the CNS workforce. This skews both the quality and utility of federal healthcare policy data and invalidates all RN data. It prevents researchers, healthcare systems and state and federal agencies from differentiating between CNS workforce data and RN workforce data, and comparing that to any other APRN data. 

Any database set up by any federal, state, regional, local, research, or private entity using the SOC categories has no specific data on more than 72,000 CNSs in the U.S. This lack of explanatory power when studying the healthcare outcomes of Americans dramatically reduces the usefulness of the data.

The classification has ramifications for CNS practice and our healthcare system. If state licensing and credentialing agencies decide to adopt the SOC classification system (which is a federal classification) when considering scope of practice issues, 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. 

Potentially, states and healthcare organizations could confine the practice of CNSs to the same level as those RNs prepared with a two-year community college nursing degree. This denies consumers positive outcomes that could be afforded through advanced CNS practice.

What's particularly vexing is that the SOC Policy Committee's decision is out of step with the rest of the federal government, nursing practice in the states and the nursing community.

Almost two decades ago, Congress recognized CNSs as APRNs in the Balanced Budget Act of 1997, which allowed CNSs to directly bill their services through the Centers for Medicare & Medicaid Services. Six years ago, the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) issued a report on nursing, Future of Nursing: Leading Change, Advancing Health, that includes a recommendation that all APRNs, including clinical nurse specialists, be allowed to practice to the full scope of their education and expertise. 

Even more recently, the Department of Veterans Affairs proposed to amend its medical regulations to permit full practice authority for all VA APRNs, including CNSs.

At the same time, more and more states are adopting the APRN Consensus Model, which identifies CNSs as one of the four types of APRNs. The model provides for uniform regulation of advanced practice nursing that aligns the interrelationships among licensure, accreditation, certification, and education.

The demand for CNS's science-based expertise is rising as our nation's healthcare needs multiply and become more complex. Clinical Nurse Specialists are often at the helm of initiatives that drive evidence based practice and policy change. The SOC Policy Committee's misclassification undermines our ability to meet that demand.

The second comment period on revising the 2010 Standard Occupational Classification for 2018 ends September 20. The SOC Committee needs to hear from a range of professionals about the importance of reclassifying CNSs as the APRNs that they are. Our nation's health hangs in the balance.

Lola A. Coke, Ph.D., ACNS-BC, FAHA, FPCNA, is an associate professor and clinical nurse specialist, Adult and Gerontological Health Nursing, at Rush University.


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