Ann Steffanic, Board Administrator
Pennsylvania State Board of Nursing
Bureau of Professional and Occupational Affairs
P.O. Box 2649
Harrisburg, PA 17105-2649

RE: 16A-513 Clinical Nurse Specialists (CNS)

Dear Ms. Steffanic:

The Hospital & Healthsystem Association of Pennsylvania (HAP), on behalf of its members, more than 250 acute and specialty hospitals and health systems, appreciates the opportunity to comment on the State Board of Nursing’s proposed regulations, which provide title protection to Clinical Nurse Specialists (CNS) as advanced practice nurses in the Commonwealth. HAP appreciates the Board’s efforts to ensure that no other person shall have the right to use the title of Clinical Nurse Specialist or the abbreviation of the title (CNS) under Act 50 of 2007, thereby ensuring that these master’s educated nurses receive their appropriate recognition as nursing professionals.

HAP supports the overall direction taken by the Pennsylvania State Board of Nursing in amending Chapter 21 to include a new subchapter to address the aforementioned title protection for Clinical Nurse Specialists. However, given the recently finalized continuing education requirements for professional registered nurses, HAP believes that Clinical Nurse Specialists may be confused about which courses from which provider sources would meet the Board’s continuing education requirements. As a result, Clinical Nurse Specialists might mistakenly believe that they meet the continuing education requirements at the time of license renewal only to discover at the time of audit that the courses that they completed may not qualify toward their requirements for continuing education.

Specifically, HAP is seeking clarification with respect to the following as it pertains to continuing education for Clinical Nurse Specialists.

• The pre-approved courses for professional registered nurses are more expansive than those proposed for the Clinical Nurse Specialist. HAP questions whether a course completed by a pre-approved provider on the professional registered nurse list but not on the pre-approved Clinical Nurse Specialist list would qualify toward continuing education completed by the Clinical Nurse Specialist. In particular, a professional registered nurse is permitted to use professional education offered through an accredited or state licensed health care organization, but a Clinical Nurse Specialist is not. Similarly, a professional registered nurse could also use a course sponsored through a national trade organization or state/regional affiliate; a national health care quality organization, such as the Joint Commission; or a course provided through a federal agency such as the Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), the Agency for Health Care Quality and Research (AHRQ), or the Health Resources and Services Administration (HRSA). But, it appears that such courses would not be pre-approved for the Clinical Nurse Specialist.
  
  In brief, it appears that the Board is being more restrictive in its list of pre-approved providers for Clinical Nurse Specialists, and HAP believes that this could create confusion in the field. It is also not clear from the proposed package why the Board might be limiting the list of pre-approved sources of continuing education for Clinical Nurse Specialists, other than perhaps the Board is extending consideration to service as a teacher, preceptor, lecturer, speaker or for publication.
• While both the final professional registered nurse continuing education regulations and the Clinical Nurse Specialist proposed regulations also provide for approval of courses by the Pennsylvania State Board of Nursing, there are differences around the timing under which that material must be submitted to the Board for approval. For instance, the professional registered nurse regulations indicate that the material must be to the Board at least 90 days prior to commencement of the activity. The proposed Clinical Nurse Specialist regulations indicate that the request for approval and the supporting documentation need to be submitted at least 60 days prior to the course. Additionally, the Clinical Nurse Specialist proposed regulations set a time frame under which the Board would approve or disapprove the request, and the professional registered nurse continuing education regulations do not provide such a time frame.
• While the professional registered nurse continuing education regulatory provisions allow for group or individual research under specific circumstances to be credited toward continuing education, the Clinical Nurse Specialist is silent in that regard. Again, HAP is seeking clarification as to whether this provision in the professional registered nurse regulations would apply to Clinical Nurse Specialists or for that matter to the Certified Registered Nurse Practitioner.
• The professional registered nurse continuing education regulatory provisions do not permit a registered nurse to have service as a teacher, preceptor, lecturer, or speaker, and for publication in a refereed journal or other scholarly publication count toward continuing education credits. Although HAP recommended that the Board consider similar provisions for the professional registered nurse, the Board did not ultimately agree with HAP’s recommendation in this regard. The Board has extended that consideration to Clinical Nurse Specialists and Certified Registered Nurse Practitioners. However, there again appear to be differences between what the Board will allow for the Clinical Nurse Specialist and Certified Registered Nurse Practitioner. In the current regulations for Certified Registered Nurse Practitioners, the Board will allow up to 4 credits for service as a teacher, preceptor, lecturer or speaker or for publication, whereas, in the proposed rule for Clinical Nurse Specialists, the Board is considering allowing up to 15 credits. Further, the Certified Registered Nurse Practitioner rule requires application to the Board be made prior to service or within 90 days of publication to assure that the Board will approve the service or publication and to allow the Board to determine the number of contact hours that will be granted, but the proposed Clinical Nurse Specialist regulations do not contain similar provisions.

Based on the above, HAP recommends the following for Board consideration.

• HAP recommends that the Board modify the pre-approved provider list for Clinical Nurse Specialists and Certified Registered Nurse Practitioners to allow for increased flexibility in course selection and to avoid potential confusion among the state’s licensed nurses.
• HAP requests that the Board clarify whether participation in a research project as the principal or co-principal investigator will be applicable to the Clinical Nurse Specialist and Certified Registered Nurse Practitioner.
• HAP recommends that the Board reconcile the differences between the Clinical Nurse Specialist and Certified Registered Nurse Practitioner with regards to the number of credits that will be approved by the Board for service as a teacher, preceptor, lecturer or speaker, and for publication in refereed journals.
• HAP recommends that the Board be clear about when it expects to receive materials for review and approval for continuing education and under what time frame that information will be reviewed and a decision rendered as to whether the Board will approve or not approve the request.

HAP appreciates the opportunity to provide comments on this proposed rulemaking. If you have any questions about HAP’s comments, please feel free to contact Mary Marshall, director, workforce and professional services at (717) 561-5312 or by email at mmarshall@haponline.org or me at (717) 561-5308 or by email at lgleighton@haponline.org.

Sincerely,

Lynn G. Leighton
Vice President
Professional & Clinical Services