January 4, 2022  
Bureau of Professional Licensing – Boards and Committees Section  
P.O. Box 30670  
Lansing, MI 48909-8170  
Dear Members of the Michigan Board of Nursing,  
We are writing in support of removing the CGFNS Qualifying Examination requirement for foreign-  
graduate nurses to obtain registered nurse (RN) licensure in the state of Michigan. In 2007,  
Governor Jennifer Granholm signed into law an amendment to Act 368 of the 1978 Public Health  
Code. This amendment removed the CGFNS Qualifying Examination as a requirement for foreign  
graduates to obtain licensure in the state of Michigan. However, in the past 4 to 5 years, foreign-  
graduate nurses have again faced difficulties in gaining their registered nurse licensure in the  
state of Michigan due to the CGFNS Qualifying Examination.  
COVID-19 has exacerbated the shortage of nurses and other health care professionals. Hospitals  
are quickly feeling the pressure of needing to provide care for patients without the staff needed.  
Filipina nurses and the Philippine Nurses Association of Michigan are eager to help meet the  
vacancies that hospitals are facing. In addition, the Michigan Health and Hospital Association and  
Health Care Association Michigan are in support of removing this rule in order to help with the  
nurse shortage. By removing this administrative rule, we will be removing a huge barrier for  
foreign-graduated nurses to join the medical workforce in our state and provide the care needed  
for our patients. Many have expressed that they have wanted to provide their services throughout  
the pandemic but have not been able to do so after not passing the examination.  
Again, we would like to express our support for the removal of this requirement as we believe it  
will help address the current nurse shortage that our state is facing. If you have any further  
questions, please do not hesitate to reach out to our offices.  
Sincerely,  
Stephanie Chang  
Paul Wojno  
Michael MacDonald  
State Senator, District 1  
Minority Floor Leader  
State Senator, District 9  
State Senator, District 10  
Rosemary Bayer  
Erika Geiss  
Jim Ananich  
State Senator, District 12  
State Senator, District 6  
State Senator, District 27  
Wayne Schmidt  
Sylvia Santana  
State Senator, District 37  
State Senator, District 3  
Jan. 5, 2022  
Department of Licensing and Regulatory Affairs  
Bureau of Professional Licensing  
Boards and Committees Section  
Administrative Rules for Board of Nursing – General Rules  
2020-70 LR  
Attention: Policy Analyst  
P.O. Box 30670  
Lansing, MI 48909  
BPL-BoardSupport@michigan.gov  
Dear Policy Analyst:  
On behalf of the Michigan Health & Hospital Association (MHA), we respectfully submit the  
following comments. The MHA and some member hospitals participated in the workgroup and  
are very grateful for the inclusive process. However, since that workgroup ended, the current  
situation facing the healthcare system has become more critical. As of Jan. 5, 2022, 4,434  
COVID-19 patients are hospitalized, with 826 in our ICUs, surpassing Michigan’s previous  
record for hospitalizations.  
To add to the complexity of patient care, there are more than 20,692 open healthcare positions  
and an average vacancy rate of 14.3 percent. The problem is worsening. Staff have reached the  
point of exhaustion, and burnout is causing early retirements and enticing individuals to leave  
healthcare for other professions. Each month, more healthcare workers exit the workforce than  
what hospitals are able to replace. This unexpected increase during the fourth COVID-19 surge  
has led health facilities to explore other possible options to bring workforce resources into the  
state to apply for Michigan licensure. With providers becoming more and more scarce,  
expanding the scope of practice for Licensed Practical Nurses (LPNs) to include  
assessments could assist in lightening the burden.  
While the MHA greatly appreciates the updated change made in the rules workgroup to R  
338.10204 (2)(B)(c), which allows an applicant to submit only one form of proof to the  
department showing they have graduated from a program with substantially similar equivalent  
education credentials as a program approved by the Michigan Board of Nursing, this does not  
take into account those providers who have already passed the NCLEX-RN offered in other  
counties. There are many international locations which now offer the NCLEX-RN such as  
Australia, Brazil, Canada, England, Hong Kong, India, Japan, Mexico, Philippines, Puerto Rico,  
South Africa, South Korea, Taiwan and Turkey. It is redundant for international nurses to be  
required to sit for one of the three options outlined (CGFNS CES, CGFNS CP, or JS&A  
evaluation) before taking the NCLEX-RN especially if they have already taken it and passed.  
Therefore, the MHA requests the following update to include allowing the passing of  
NCLEX-RN in English at an international location as a form of educational proof by adding  
another section, (c)(iv) and clarifying language to reflect the change in (3).  
(c) The applicant is a graduate of a registered professional nurse education program or an  
equivalent education program that is outside the United States…the applicant submits 1 of the  
following to the department that shows he or she graduated from a program with substantially  
similar equivalent education credentials as a program approved by the board………..  
(iii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from Josef Silny  
& Associations, Inc. International Education Consultants (JS&A).  
(iv) Proof of passage of the NCLEX-RN in English offered at an international location.  
(3) The department shall evaluate the proof of substantially equivalent education credentials in  
this subrule before the applicant receives authorization from the department to take the NCLEX-  
RN examination if educational proof is not the NCLEX-RN exam itself.  
Please reach out with any questions.  
Respectfully submitted,  
Adam Carlson  
Senior Vice President, Advocacy  
Michigan Health & Hospital Association  
Desk: (517) 886-8245 | Cell: (269) 757-2479  
acarlson@mha.org  
17356 Northland Park Ct, Southfield MI 48075  
Phone: (586)774-3662 Website: pnamichigan.org  
Email:pnamichigan2020@gmail.com  
To: Bureau of Professional Licensing  
January 5, 2022  
Notice of Public Hearing  
Board of Nursing - General Rules (MOAHR #2020-70 LR)  
Lansing, MI  
Dear Sir/Madam,  
Good day and Happy New Year. The Philippine Nurses Association of Michigan (PNAM)  
CGFNS Removal Task Force would like to submit this comment to the Public Hearing of the  
Board of Nursing - General Rules. The Task Force supports the amendments that is being done  
to the General Rules particularly in regards to examination and licensure of applicants who are  
educated outside the U.S. [R 338.10204, Rule 204 (c) and R 338/10208 (Rule 1208 (c)].  
However, we would also like to have a more explicit language on the certification from  
CGFNS certification program to – “exclude or remove the CGFNS Qualifying Examination as  
part of the certification requirement” (under subsections ii of each Rules).  
PNAM is a nursing organization in MI whose members are mostly nurses. We are personally  
aware of the current critical shortage of RNs in MI and across the U.S. who will care for  
patients with the coronavirus (COVID-19) pandemic. At the same time, shortages due to  
nurses leaving the profession due to burnout experienced by RNs working non-stop, and the  
projected retirement of over 500,000 RNs by 2022. We believe the abovementioned amended  
rules - allowing for several options, besides the CGFNS certification program, for foreign  
graduates to obtain license to work as an RN in the U.S. will have a significant positive impact  
to the critical RN shortage we are experiencing. This will allow us to become more competitive  
with other states in recruiting qualified nurses.  
However, we would like to request for a more explicit language of excluding or removing the  
CGFNS Qualifying Examination as part of the certification from CGFNS program. This  
requirement in the CGFNS certification program is a huge barrier for foreign-graduates from  
coming to MI, especially, those who have already passed the National Council Licensure  
Examination for Registered Nurses (NCLEX-RN©). As noted recently, Henry Ford Hospital  
announced their plan to recruit Filipino nurses; yet, Filipino nurses would rather apply to  
another state because of the CGFNS certification requirement in MI. In order for foreign  
graduates to receive the certification letter, the applicant must complete three process: 1) verify  
their nursing education, 2) pass the CGFNS Qualifying Examination, and 3) document that  
they are proficient in the English language. We believe that verification of applicant’s  
education and documentation of English proficiency are important documents; however, the  
predictor CGFNS Qualifying Examination may be an added financial burden for foreign  
graduates. It is also counterintuitive and unnecessary, particularly for those who have passed  
the NCLEX-RN©, as CGFNS has been used as a predictor of passing the NCLEX-RN. At the  
same time, On June 14, 2007, then Governor Jennifer Granholm signed into a law an  
PNAM Mission Statement: As a professional organization, PNAM will uphold the positive image and  
welfare of its constituent members,promote professional excellence and contribute significant  
outcomes to healthcare and society. PNAM is a 501 (c)(3) nonprofit organization  
17356 Northland Park Ct, Southfield MI 48075  
Phone: (586)774-3662 Website: pnamichigan.org  
Email:pnamichigan2020@gmail.com  
amendment to Act 368 of the 1978 Public Health Code [HB 4207 (2007) removing CGFNS  
Qualifying Examination as a requirement for foreign graduate nurses. We are including a  
letter signed by several legislators supporting the removal of the CGFNS Qualifying  
Examination for a requirement.  
In summary, we fully support the amendments to R 338.10204, Rule 204 (c) and R 338/10208  
Rule 1208 (c); however, we would like a more explicit language for the Section c, subsection ii  
- “certification letter from CGFNS certification program verifying educational documents and  
language proficiency”, which will then exclude or remove the CGFNS Qualifying  
Examination as part of the CGFNS certification program requirement.  
We appreciate your commitment to the nursing profession and we urge for the approval of  
these amendments as soon as possible.  
Respectfully,  
Meriam Caboral-Stevens  
Meriam Caboral-Stevens, PhD, RN, NP-C  
In behalf of the PNAM CGFNS Removal Task Force  
Concepcion Sumalde,  
Sofia Bole,  
Reglita Laput,  
Wilmar Suan,  
Dr. Aniceta Vista,  
Dr. Phil Mangahas,  
Martha Cabarios,  
Amy Risbold,  
Trinie Alair  
Ellen Laboga,  
Corazon Gabarda,  
Corazon Galinato,  
Jose Vicente Faderon  
Fe San Agustin  
Nina McCauley  
Ellen Dioso  
Kino Anuddin  
Dr. Tsu-Yin Wu  
Cc: MI BON  
PNAM Mission Statement: As a professional organization, PNAM will uphold the positive image and  
welfare of its constituent members,promote professional excellence and contribute significant  
outcomes to healthcare and society. PNAM is a 501 (c)(3) nonprofit organization  
Jan. 5, 2022  
Department of Licensing and Regulatory Affairs  
Bureau of Professional Licensing  
Boards and Committees Section  
Administrative Rules for Board of Nursing – General Rules  
2020-70 LR  
Attention: Policy Analyst  
P.O. Box 30670  
Lansing, MI 48909  
BPL-BoardSupport@michigan.gov  
Dear Policy Analyst:  
On behalf of the Michigan Health & Hospital Association (MHA), we respectfully submit the  
following comments. The MHA and some member hospitals participated in the workgroup and  
are very grateful for the inclusive process. However, since that workgroup ended, the current  
situation facing the healthcare system has become more critical. As of Jan. 5, 2022, 4,434  
COVID-19 patients are hospitalized, with 826 in our ICUs, surpassing Michigan’s previous  
record for hospitalizations.  
To add to the complexity of patient care, there are more than 20,692 open healthcare positions  
and an average vacancy rate of 14.3 percent. The problem is worsening. Staff have reached the  
point of exhaustion, and burnout is causing early retirements and enticing individuals to leave  
healthcare for other professions. Each month, more healthcare workers exit the workforce than  
what hospitals are able to replace. This unexpected increase during the fourth COVID-19 surge  
has led health facilities to explore other possible options to bring workforce resources into the  
state to apply for Michigan licensure. With providers becoming more and more scarce,  
expanding the scope of practice for Licensed Practical Nurses (LPNs) to include  
assessments could assist in lightening the burden.  
While the MHA greatly appreciates the updated change made in the rules workgroup to R  
338.10204 (2)(B)(c), which allows an applicant to submit only one form of proof to the  
department showing they have graduated from a program with substantially similar equivalent  
education credentials as a program approved by the Michigan Board of Nursing, this does not  
take into account those providers who have already passed the NCLEX-RN offered in other  
counties. There are many international locations which now offer the NCLEX-RN such as  
Australia, Brazil, Canada, England, Hong Kong, India, Japan, Mexico, Philippines, Puerto Rico,  
South Africa, South Korea, Taiwan and Turkey. It is redundant for international nurses to be  
required to sit for one of the three options outlined (CGFNS CES, CGFNS CP, or JS&A  
evaluation) before taking the NCLEX-RN especially if they have already taken it and passed.  
Therefore, the MHA requests the following update to include allowing the passing of  
NCLEX-RN in English at an international location as a form of educational proof by adding  
another section, (c)(iv) and clarifying language to reflect the change in (3).  
(c) The applicant is a graduate of a registered professional nurse education program or an  
equivalent education program that is outside the United States…the applicant submits 1 of the  
following to the department that shows he or she graduated from a program with substantially  
similar equivalent education credentials as a program approved by the board………..  
(iii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from Josef Silny  
& Associations, Inc. International Education Consultants (JS&A).  
(iv) Proof of passage of the NCLEX-RN in English offered at an international location.  
(3) The department shall evaluate the proof of substantially equivalent education credentials in  
this subrule before the applicant receives authorization from the department to take the NCLEX-  
RN examination if educational proof is not the NCLEX-RN exam itself.  
Please reach out with any questions.  
Respectfully submitted,  
Adam Carlson  
Senior Vice President, Advocacy  
Michigan Health & Hospital Association  
Desk: (517) 886-8245 | Cell: (269) 757-2479  
acarlson@mha.org  
Comments to Rule Set 2020-70 LR  
The Health Care Association of Michigan (HCAM), which represents 362 skilled nursing facilities across the  
state, would like to offer our strong support of proposed rule set 2020-70 LR. In light of the significant  
workforce challenges experienced by long-term care the rule set is a welcomed and material improvement to  
the current rules that will ease the ability for Michigan providers to attract nurses to our state.  
While sectors across the economy face similar challenges, the workforce shortage in the health care sector,  
and nursing facilities specifically, is uniquely challenging. According to data from the U.S. Bureau of Labor  
Statistics, the long-term care industry is facing the worst job loss among all health care providers. Nationally,  
220,000 jobs have been lost during the pandemic, equaling a 14% decrease in the workforce. In Michigan, an  
HCAM survey of membership indicates a 17% decrease in the workforce from pre-pandemic levels, with  
currently more than 8,000 job openings. A survey by our national association shows that 99% of nursing  
facilities in the U.S. are facing a staffing shortage.  
Providers have recognized these dedicated caregivers with retention bonuses, additional paid time off, health  
care benefits, 401k contributions, referral bonuses, and tuition and student loan reimbursement. Wages have  
increased significantly, with many facilities paying CNAs well over $20 per hour.  
Unfortunately, the workforce challenges remain, leaving many facilities no choice but to refuse admissions and  
close entire units due to lack of staff. If we do not implement policies to address these challenges, we risk the  
ability for residents to access the 24/7 nursing care they need.  
Michigan is in the minority of states which require the passage of the Commission on Graduates of Foreign  
Nursing Schools (CGFNS) Qualifying Examination for those nurses who have been educated outside of the  
United States or Canada. This requirement creates an extra burden on international nurses, making it more  
difficult for Michigan providers to attract, recruit, and hire these nurses to our state. Neighboring states,  
including Ohio, do not require passage of the CGFNS Qualifying Exam, and multi-state providers have  
experienced nurses taking positions in Ohio rather than Michigan to avoid this additional burden.  
The CGFNS Qualifying Examination requirement is unnecessary for these nurses who have already taken the  
NCLEX, which is now widely available across the globe. Additionally, the CGFNS Qualifying Examination is  
only offered four times a year in limited locations, and testing has been limited during the COVID-19 pandemic.  
To avoid these extra burdens for internationally trained nurses interested in working in Michigan, it is prudent to  
remove the CGFNS Qualifying Examination requirement.  
Rich Farran  
V.P. Government Services  
Health Care Association of Michigan  
7413 Westshire Drive · Lansing, MI 48917 · P: (517) 627-1561 · F: (517) 627-3016 · www.hcam.org  
January 5, 2022  
Attention: Policy Analyst  
Michigan Department of Licensing and Regulatory Affairs  
Bureau of Professional Licensing  
Boards and Committees Section  
P.O. Box 30670  
Lansing, MI 48909-8170  
Submitted via email to: BPL-BoardSupport@michigan.gov  
Re: Proposed Changes to the Board of Nursing – General Rules  
Dear Policy Analyst:  
On behalf of Henry Ford Health System (Henry Ford), I want to thank you for the opportunity to  
comment on the Administrative Rules for Board of Nursing – General Rules (Rule Set 2020-70 LR).  
Henry Ford supports the proposed revisions to expand options for internationally educated nurses to  
show equivalent education credentials as other programs approved by the board, as these changes  
would allow Henry Ford to more easily recruit qualified nurses who graduated from a program outside  
the United States to fill staffing needs that have been exacerbated by the COVID-19 public health  
emergency.  
Henry Ford is a Michigan-based, not-for-profit corporation and one of the country’s largest integrated  
health care systems, with over 33,000 employees. Headquartered in Detroit, we have been committed  
to improving the health and wellbeing of the community for over 100 years. In the Detroit area, Henry  
Ford includes four acute-care hospitals, including our flagship, Henry Ford Hospital (HFH), a large  
academic hospital located within the city of Detroit; an inpatient psychiatric facility; and a network of  
outpatient medical facilities staffed by members of the Henry Ford Medical group (HFMG). Henry Ford  
Allegiance Health (HFAH) has served the Jackson community since 1918. HFAH provides comprehensive,  
advanced inpatient and outpatient care, and works with an integrated network of physicians, the  
Jackson Health Network, which serves more than 40 facilities. Across our health system, Henry Ford  
employs more than 6,650 nurses. Two of our hospitals (HFH and HFAH) are designated as Magnet  
hospitals, meaning that they have been recognized for high quality nursing and a dedication to the  
nursing profession.  
Henry Ford has been heavily impacted by the nursing shortage, as have other health systems across the  
state. A September 2020 report published by the Michigan Department of Health and Human Services  
showed that 55.9% of registered nurses (RNs) and 54.9% of licensed practical nurses (LPNs) are 45 years  
of age or older.i This means that more than half of the current nursing workforce is nearing retirement  
age in the next two decades. Current retirement is also a pressing issue, as 10.2% of RNs and 9.7% LPNs  
included in the state’s report were already retired. The two-year COVID-19 pandemic has only  
exacerbated issues with nursing staffing. Older workers are concerned about being exposed to COVID-  
19, and many nurses feel stressed and overworked.ii These impacts have contributed to an increase in  
turnover among all nursing staff in 2020 and 2021, with turnover rates nearing 20% throughout the  
country.iii  
As Michigan endures another surge in COVID-19 due to the Delta variant (and now the Omicron variant),  
the increase in hospitalizations and stress among workers has caused hospitals to make cuts to services  
or resort to costly solutions to contend with staff shortages. To address gaps, hospitals have had to rely  
on travel nursing agencies to provide workers, or request aide from the federal government. Contracts  
for travel nurses are extremely expensive, up to $75,000 for three months of work, which is  
unsustainable for hospitals already strained by the pandemic. Henry Ford reduced our available beds by  
120 on September 13, 2021 because we did not have the nurses or other workers available to staff  
them.iv In November of 2021, Henry Ford had 1,000 open positions for nurses across the health system  
for which we have had difficulty filling due to the shortage of available nurses and the intense price  
competition by travel nursing agencies.  
Recruiting international nurses is an important tool that hospitals have to address staffing shortages and  
provide high-quality and safe care for patients. Michigan’s nursing licensure requirements, however,  
make the state a less attractive prospect for applicants who studied outside the United States. The  
higher burden that Michigan’s requirements place on internationally educated nurses to complete the  
Commission on Graduates of Foreign Nursing Schools (CGFNS) Certification Program, which adds extra  
time and cost for applicants, means that it may be more difficult for hospitals in Michigan to attract  
candidates than hospitals in other states. In response to ongoing pandemic-related labor shortages,  
Henry Ford is looking to recruit a large number of nurses from the Republic of the Philippines, where  
proficiency in English is high and the nursing standards are similar to those in the United States. The  
licensing process, however, presents a large administrative and financial burden for both the applicants  
and the healthcare system.  
Henry Ford is in support of expanding the options for internationally educated nurses to prove their  
education credentials beyond just the CGFNS Certification Program. The CGFNS Certification Program  
requires the CGFNS Qualifying Exam, which is a large financial burden for internationally educated  
nurses and limits Michigan’s workforce from expanding to its full capacity in the short-term. The cost of  
the certification and the test has posed a barrier to Henry Ford as we work to recruit international  
nurses, as applicants must pay and sit for the additional examination on top of the National Council  
licensure Examination for Registered Nurses (NCLEX-RN).  
Only six other states require that international nurses complete the CGFNS Certification Program, so  
expanding the options for professional nurses to include the CGFNS Credentials Evaluation Service or the  
Evaluation of Foreign Education Credential for Boards of Nursing from Josef Silny & Associates, Inc.  
International Educational Consultants (JS&A) brings Michigan into alignment with the vast majority of  
states that include other options in their licensing rules. The draft rules also expand these credentials  
evaluation flexibilities to internationally educated nurses who have passed the NCLEX-RN examination  
and have been licensed in another state for less than five years. The draft rules also allow for an  
exemption to the credentials requirements for those who have passed the NCLEX-RN examination and  
have been practicing in good standing for more than five years. These changes to the Board of Nursing  
General Rules will ensure consistency in the requirements across states; provide pathways for licensure  
by endorsement for the international workforce; and remove administrative requirements, making it  
easier to recruit nurses to support our current workforce, which is facing extreme strain and burn out  
from the public health emergency.  
We anticipate health systems will continue to face staffing shortages now and into the future, due to  
widespread burnout and turnover from the ongoing public health emergency, retirements among an  
aging workforce, an aging population requiring more medical care, and a limited number of candidates  
entering the field. As such, Henry Ford is supportive of a variety of methods to increase the healthcare  
workforce in the short- and long-term. One such solution to attract more nurses to the state could  
include modifying the licensing process for internationally educated nurses to be more like the  
reciprocal licensing permitted to Canadian nurses, specifically for nurses educated in the Philippines. The  
Philippines has similar education requirements and licensing practices to the United States and Canada,  
and nurses educated in the Philippines are highly qualified to meet the standards expected of practicing  
nurses in Michigan. Henry Ford has historically recruited applicants from both Canada and the  
Philippines to meet its workforce needs and believes that the recruitment process would be more  
efficient and equitable if changes were made to allow Michigan licensing reciprocity for nurses educated  
in the Philippines who have already passed the NCLEX-RN and graduated from a nursing program  
accredited in the Philippines.  
Again, I would like to thank the Department of Licensing and Regulatory Affairs for considering these  
proposed rule changes and appreciate the opportunity to offer comment.  
Sincerely,  
Eric Wallis DNP, MSA, RN, NE-BC, FACHE  
SVP Patient Care & System Chief Nursing Officer  
Henry Ford Health System  
i Michigan Public Health Institute (2020). 2020 Survey of Michigan Nurses: Survey Summary Report. Michigan  
Department of Health and Human Services. Available at:  
https://www.michigan.gov/documents/mdhhs/MI_Nurse_Survey_Report_2020_final_705633_7.pdf  
ii Walsh, D. (2021). Unhealthy numbers: Hospitals shut down beds as staffing woes reach critical mass. Crain’s  
Detroit Business. Available at: https://www.crainsdetroit.com/health-care/health-care-labor-shortage-predates-  
covid-19-latest-surge-deals-another-critical-blow  
iii NSI Nursing Solutions (2021). 2021 NSI National Health Care Retention and RN Staffing Report. Available at:  
https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf  
iv Bouffard, K. (2021). Henry Ford hospitals trim beds due to staffing shortages. Detroit News. Available at:  
https://www.detroitnews.com/story/news/local/detroit-city/2021/09/13/henry-ford-health-hospitals-trim-beds-  
due-staffing-shortage/8324082002/  
To the Michigan Board of Nursing,  
Today I am presenting my request for CNS licensure modification. My request is to allow for the  
National Certification Corporation for the Obstetric, Gynecological and Neonatal Nursing Specialties to  
be accepted as a certification organization in rule R 338.10404c subrule (1) (c) (i) of the Board of  
Nursing General Rules document. Below is my statement to the Board:  
Thank you for allowing me to present my request for CNS licensure modification to the board. I lament  
that I am not able to personally present this request today, but I am hoping the importance of this  
request is not diminished by my absence.  
First, I'd like to give you a little background about me- I have been a nurse for 12 years and knew  
immediately I wanted to be a perinatal nurse. I have always thought I was one of the lucky ones in  
finding a career that I absolutely loved. Being a part of such an important time in one's life is such an  
honor. However, through my early years as a nurse, I became aware of the status of maternal and  
newborn mortality in our nation and I wanted to do more- no, let me rephrase that- I felt a duty to do  
more. I wanted to be able to lead a bigger impact for our moms and babes. I honestly didn’t even know  
what a CNS was until I did a Google search for advanced practice options in perinatal nursing. When I  
came across an article about a perinatal CNS, I said to myself- that’s me, that’s what I’m meant to do.  
Now, for the last almost 4 years, I have dedicated my career here in Kalamazoo to improving the care,  
education, and lives of not only our moms and babes, but also the staff that care for them. I moved my  
entire family and life to Michigan solely for this position, which hopefully attests to the passion and  
dedication I have for this role. I’m proud to be a part of the changes we are making here and hopefully  
proving that perinatal CNSs are essential to changing the course of maternal and newborn mortality in  
this country.  
I come before you today to ask that licensure be modified to appreciate and support the significance  
of the speciality of perinatal nursing for three reasons. The first reason is that, although I have  
completed my studies and obtained three certifications in perinatal nursing, the current rules for  
licensure in Michigan do not allow for me to be licensed as a CNS. I recognize almost every day that  
there are still those who do not know what a CNS is and I am constantly advocating that we are not just  
‘educators’, which I am many times referred to. I now feel I also have to advocate for perinatal CNSs  
specifically, as I feel we are overlooked and many times not recognized as an essential and necessary  
field of CNSs. When I was hired at my current employer, I was actually called a Clinical Outcomes  
Specialist and I was the only one in that job description with a CNS background. I know many other  
perinatal CNSs are called OB educators or have other titles besides a CNS- many of us are not  
recognized for what we are, which does not help advocate for CNSs in general.  
As someone who lives in evidence and research, I looked into the other states in the midwest to see  
what their requirements for licensure are. Four out of five states allow multiple national certifications to  
be accepted, one of them being National Certification Corporation for the Obstetric, Gynecological and  
Neonatal Nursing Specialties (NCC). The fifth state only required transcripts for licensure. The NCC is  
actually already an accepted credentialing body by Michigan for Nurse Practitioners, but not CNSs. This  
organization is specific to perinatal nursing and therefore, provides the most accurate representation of  
one’s knowledge in the discipline. From the NCC I have obtained my RNC-OB, which is specific to  
inpatient obstetrics, my C-EFM, which is certification in fetal monitoring, and my C-ONQS, which is  
certification in obstetric and neonatal quality and safety. I feel these, along with my transcripts from a  
dedicated perinatal CNS academic track, should allow for recognition of myself as a CNS.  
The second reason is related to my requirements for my job. Thankfully, my employer has  
recognized those of us that are CNSs and my job title was changed to Clinical Nurse Specialist- I  
thought this was a huge win for us. Around the same time, Michigan allowed for licensure of CNSs as  
well, I was so excited! That excitement was short lived however, as I saw only ACNN was accepted as  
a credentialing body for CNSs. As my Master’s degree accreditation was solely for perinatal nursing, I  
did not meet the requirements to sit for any of the ACNN exams and was disappointed I still could not  
obtain licensure in Michigan. Even though I could not be licensed, I was still able to function as a CNS in  
my role and that was what mattered to me- that I could still work to improve maternal and newborn care.  
However, my job description recently changed and now requires me to have a license. They are  
currently looking for a different position for me that does not require the licence. Although it would not  
be ideal, I would take another position so that I can continue my work, even if I’m no longer called a  
CNS. However, I do not want to do that without first advocating for CNSs in general and attempting to  
keep the job title that I feel I deserve.  
Lastly, I feel very strongly that by accepting and recognizing perinatal CNSs as a distinct profession  
in the CNS field, we are acknowledging the need for specialized skills and knowledge that is essential to  
combating the disparities and barriers that are driving our maternal and newborn mortality rates in this  
country. We rank last in the world for developed countries in maternal care. This is unacceptable. We  
need more perinatal CNSs and the speciality needs to be recognized in order to fight the change to  
reduce this rate. Perinatal patients have specialized needs and there are multiple evidence based  
practices that need to be put into place. Through the years of nursing before I became a CNS, I worked  
in a variety of places and most of them were years behind evidence based practice. Unfortunately, I  
have come to realize this is more the norm instead of the exception in this nation. However, many of  
these sites have no one to help them that is dedicated with the knowledge and skills of perinatal nursing.  
Until we recognize this specialized need as a country, we cannot expect change. Many perinatal units  
are seen as an afterthought, or the black sheep of the hospital- red headed step child I’ve heard it  
referred to as well. When I started my position at my current hospital, nothing had changed in 10 years.  
Over the last 4 years we have implemented numerous EBP including quantitative blood loss, safe sleep,  
nitrous oxide, reduction of primary cesarean rate, hemorrhage and hypertension bundles, glucose gel for  
newborns as well as eat, sleep, console (which is an EBP for neonatal abstinence syndrome), and Baby  
Friendly among various others. Our primary cesarean section rate is one of the lowest in the state, and  
we have one of the highest breastfeeding rates. I absolutely could not have done any of these without  
the support of my administration; however, I also feel many of these would not have been done without  
my director advocating specifically for a perinatal CNS on the unit as well.  
Thank you all for allowing me the time to plead my case at this meeting. I appreciate the  
consideration for revising the rules for CNS licensure in Michigan and hope my story has made an  
impact on each of you.  
Respectfully,  
Krista Jackson, MSN, RNC-OB, C-ONQS, C-EFM  
From:  
BPL-BoardSupport  
To:  
Ditschman, Andria (LARA)  
Subject:  
Date:  
FW: Comments on Proposed Rule changes for Board of Nursing-General Rules  
Monday, January 3, 2022 6:59:20 AM  
Attachments:  
Ciena Healthcare supports the proposed rule change for the Board of Nursing.docx  
From: Allyson Bakewell <abakewell@cienahmi.com>  
Sent: Thursday, December 30, 2021 2:17 PM  
To: BPL-BoardSupport <BPL-BoardSupport@michigan.gov>  
Subject: Comments on Proposed Rule changes for Board of Nursing-General Rules  
CAUTION: This is an External email. Please send suspicious emails to abuse@michigan.gov  
Ciena Healthcare operates 47 skilled nursing facilities in Michigan and employs almost 1000  
nurses. Ciena Healthcare strongly supports the Board of Nursing’s proposed rule change  
R338.10204 pertaining to graduates of registered professional nurse education programs  
outside the United States. We encourage the BON to adopt the revised rules as soon as  
possible.  
Please see attached comments and let me know if you have any questions.  
Thank you!  
--  
Allyson Bakewell, RN, BSN, MBA  
Director of Talent Acquisition  
4000 Town Center, Suite 2000, Southfield, MI 48075  
C (248) 508-0941 O (248) 386 0300 F (248) 386 0314  
The above email is for the intended recipient only and may be confidential and/or protected under the Quality Assurance privilege. If you  
are not the intended recipient, please immediately advise the sender and delete the email and any attachments. Unauthorized use or  
distribution is prohibited and may be unlawful.  
Ciena Healthcare operates 47 skilled nursing facilities in Michigan and employs almost 1000  
nurses. Ciena Healthcare supports the Board of Nursing’s proposed rule change  
R338.10204 pertaining to graduates of registered professional nurse education programs  
outside the United States.  
The current rule allows for only the certification from the CGFNS Certification Program (CP),  
and the proposed option to provide other credentials, the CES from the CGFNS or the evaluation  
from Josef Silny is important.  
The acceptance of the CES will allow Michigan to be competitive with other states which  
already have this option for recruitment of foreign educated nurses. This will allow Michigan to  
recruit foreign educated nurses who may already have passed the NCLEX and can provide  
credential review (CES) without the additional requirement of a test which is included in the CP.  
While many states require some aspects of certification by the CGFNS, only Michigan requires the CP  
– including CGFNS exam, with no alternative, for both licensure by exam and by endorsement from  
another state. Most states only require the CES and English proficiency. This exam creates a hardship  
for international nurses because:  
•
•
It is an additional comprehensive nursing exam, much like the NCLEX, and nurses are already  
taking/or took the NCLEX  
The CGFNS exam was developed as a preparation for the NCLEX, and a predictor of which  
nurses would succeed on the NCLEX. In the past, states had a hard time determining which  
international nurses likely to meet the licensure requirements in the US, and be able to pass the  
NCLEX. But, the NCLEX has been available around the world since 2005 so most international  
nurses study for and take the NCLEX exam instead of the CGFNS exam.  
The CGFNS exam is only given 4 times a year in various locations around the world, and needs  
to be scheduled 2 months in advance.  
•
•
•
With Covid, testing centers have been closed and unreliable.  
The CGFNS exam must be taken within 2 years of application. Many nurses took the exam in the  
past and have to take it again for MI.  
•
The hurdle of one more test (and the possibility of not passing) represents an additional barrier to  
a nurse’s ability to immigrate.  
Ciena Healthcare Experience: Since other states do not require the CP, nurses decline our offer to  
work in MI in favor of other states that do not require the exam. Ciena has interviewed  
approximately 100 international nurses with a number declining our offer in favor of other states.  
Lately, close to 30% of the nurses interviewed have declined as a result of concern over the test.  
Since the MI Board requires the CGFNS by exam or endorsement, hiring nurses into another state  
and transferring to MI is not an option.  
In addition, international nurse recruiting companies are declining to try to recruit nurses for  
us, stating the difficulty in getting nurses who are interested in Michigan due to the CGFNS CP  
requirements.  
Michigan is experiencing a nursing shortage and by changing the CGFNS requirements, we will be more  
competitive in recruiting foreign nurses to help relieve the shortage.  
Proposed rule change:  
(c) The applicant is a graduate of a registered professional nurse education program or an  
equivalent education program that is outside the United States and has been certified pursuant to  
R 338.10208 by the Commission on Graduates of Foreign Nursing Schools (CGFNS) or its  
successor agency, to have the applicant submits 1 of the following to the department that  
shows he or she graduated from a program with substantially similar equivalent education  
credentials as a program approved by the board: , or is exempt from CGFNS certification under  
R 338.10208(3) and (4).  
(i) A Credentials Evaluation Service (CES) academic report from the Commission on  
Graduates of Foreign Nursing Schools (CGFNS) or its successor agency.  
(ii) A certification from the CGFNS Certification Program (CP) or its successor agency.  
(iii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from  
Josef Silny & Associations, Inc. International Education Consultants (JS&A).  
Nursing General Rules - ORR 2020-070 LR  
Public Comment Summary  
Rules Committee Recommendations and Board Review of January 5, 2022, Public Comments  
Testimony/Comments Received:  
Allyson Bakewell, Director of Talent Acquisition, Ciena Healthcare (Ciena)  
Adam Carlson, Senior V. P. Advocacy, Michigan Health & Hospital Association (MHA)  
Stephanie Chang, State Senator, District 1, Minority Floor Leader; Paul Wojno, State Senator, District 9; Michael MacDonald,  
State Senator, District 10; Rosemary Bayer, State Senator, District 12; Erika Geiss, State Senator, District 6; Jim Ananich,  
State Senator, District 27; Wayne Schmidt, State Senator, District 37; and Sylvia Santana, State Senator, District 3  
Richard Farran, V.P. of Government Services, Health Care Association of Michigan (HCAM)  
Krista Jackson, MSN, RNC-OB, C-ONQS, C-EFM  
Meriam Caboral-Stevens, PNAM CGFNS Removal Task Force, Philippine Nurses Association of Michigan (PNAM)  
Eric Wallis, SVP Patient Care & System Chief Nursing Officer, Henry Ford Health System  
CGFNS – Multiple Rules  
Rule Numbers  
Commenter  
Comment  
Bakewell/Ciena  
Supports the change to add alternatives to CGFNS: allows Michigan to be competitive with other  
states and to recruit foreign educated nurses who have passed he NCLEX and can provide credential  
review; only Michigan requires the CP, including the CGFNS examination for licensure by  
examination and endorsement; the examination creates hardship on nurses; and Michigan is  
experiencing a nurse shortage.  
Senator Stephanie Remove the CGFNS qualifying examination requirement for foreign graduate nurses to obtain  
Chang  
registered nurse licensure in Michigan.  
Caboral/PNAM  
Supports alternatives to CGFNS. Would also suggest changing language where CGFNS is  
referenced, add the following language: “certification letter from CGFNS certification program  
verifying educational documents and language proficiency.” This will exclude or remove the  
CGFNS Qualifying Examination as part of the CGFNS certification program requirement.  
March 3, 2022  
In order for foreign graduates to receive the certification letter, the applicant must complete three  
processes:  
1) verify their nursing education,  
2) pass the CGFNS Qualifying Examination, and  
3) document that they are proficient in the English language.  
We believe that verification of applicant’s education and documentation of English proficiency are  
important documents; however, the predictor CGFNS Qualifying Examination may be an added  
financial burden for foreign graduates.  
Carlson/MHA  
There are many international locations which now offer the NCLEX-RN such as Australia, Brazil,  
Canada, England, Hong Kong, India, Japan, Mexico, Philippines, Puerto Rico, South Africa, South  
Korea, Taiwan and Turkey. It is redundant for international nurses to be required to sit for one of the  
three options outlined (CGFNS CES, CGFNS CP, or JS&A evaluation) before taking the NCLEX-  
RN especially if they have already taken it and passed. Requests this section to include allowing the  
passing of NCLEX-RN in English at an international location as a form of educational proof by  
adding another section, (c)(iv) and clarifying language to reflect the change in (3).  
Change R 338.10204(2)(B)(c) as follows:  
(c) The applicant is a graduate of a registered professional nurse education program or an equivalent  
education program that is outside the United States…the applicant submits 1 of the following to the  
department that shows he or she graduated from a program with substantially similar equivalent  
education credentials as a program approved by the board………..  
(iii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from Josef Silny &  
Associations, Inc. International Education Consultants (JS&A).  
(iv) Proof of passage of the NCLEX-RN in English offered at an international location.  
(3) The department shall evaluate the proof of substantially equivalent education credentials in this  
subrule before the applicant receives authorization from the department to take the NCLEX-RN  
examination if educational proof is not the NCLEX-RN exam itself.  
Farran/ HCAM  
Supports the change to add alternatives and would like to eliminate any requirement to take the  
CGFNS for the following reasons: workforce challenges; Michigan is in the minority of states which  
require passage of the CGFNS qualifying examination for nurses educated outside of the US and  
Canada; the qualifying examination is not necessary for nurses who have passed the NCLEX; and  
2
the qualifying examination is only offered 4 times a year in limited locations.  
Wallis/Henry  
Ford  
Henry Ford is in support of expanding the options for internationally educated nurses to prove their  
education credentials beyond just the CGFNS Certification Program. The CGFNS Certification  
Program requires the CGFNS Qualifying Exam, which is a large financial burden for internationally  
educated nurses and limits Michigan’s workforce from expanding to its full capacity in the short-  
term. The cost of the certification and the test has posed a barrier to Henry Ford as we work to  
recruit international nurses, as applicants must pay and sit for the additional examination on top of  
the National Council licensure Examination for Registered Nurses (NCLEX-RN).  
The draft rules also expand these credentials evaluation flexibilities to internationally educated  
nurses who have passed the NCLEX-RN examination and have been licensed in another state for  
less than five years. The draft rules also allow for an exemption to the credentials requirements for  
those who have passed the NCLEX-RN examination and have been practicing in good standing for  
more than five years. These changes to the Board of Nursing General Rules will ensure consistency  
in the requirements across states; provide pathways for licensure by endorsement for the  
international workforce; and remove administrative requirements, making it easier to recruit nurses  
to support our current workforce, which is facing extreme strain and burn out from the public health  
emergency.  
Henry Ford is supportive of a variety of methods to increase the healthcare workforce in the short-  
and long-term. One such solution to attract more nurses to the state could include modifying the  
licensing process for internationally educated nurses to be more like the reciprocal licensing  
permitted to Canadian nurses, specifically for nurses educated in the Philippines. The Philippines  
has similar education requirements and licensing practices to the United States and Canada, and  
nurses educated in the Philippines are highly qualified to meet the standards expected of practicing  
nurses in Michigan. Henry Ford has historically recruited applicants from both Canada and the  
Philippines to meet its workforce needs and believes that the recruitment process would be more  
efficient and equitable if changes were made to allow Michigan licensing reciprocity for nurses  
educated in the Philippines who have already passed the NCLEX-RN and graduated from a nursing  
program accredited in the Philippines.  
Rules Committee The Rules Committee agrees with the comments that an applicant should have the opportunity to show educational  
3
Response  
program equivalency without having to take an examination in addition to the NCLEX, but the Rules Committee does  
not agree with the comments to entirely remove the CGFNS CP option or the reference to the certification and  
examinations in the rules as the proposed rules include various options to show educational equivalency in addition to  
using the CGFNS CP pathway. The Rules Committee recommends keeping CGFNS CP as one of the options as there  
may be applicants who have already completed this pathway or are in the process of completing this pathway for  
licensure in Michigan.  
The Rules Committee does not recommend adopting MHA’s comment to allow passing the NCLEX in English as proof  
of educational program equivalency, in order to sit for the NCLEX. The options to prove educational program  
equivalency have already been broadened in the proposed rules to accept alternatives in addition to the CGFNS CP.  
Passing the NCLEX is not proof of educational program equivalency.  
Although the NCLEX is offered in other countries, in order to sit for the examination an applicant must have permission  
from a state, Australia, or Canada. Pursuant to MHA’s comment, if the Board determines to allow applicants who  
graduated from a program outside of the United States, and who have already passed the NCLEX examination but have  
not yet been licensed in another state or Australia, to have the option to apply for licensure in Michigan without retaking  
the NCLEX, clarifying language could be added to R 338.10208(1)(c) and R 338.10212(1)(c).  
The Rules Committee will not comment on the request from Henry Ford to treat applicants from the Philippines similar  
to applicants from Canada, as this would be a legislative change.  
Board Response  
The Board agrees with the comments that an applicant should have the opportunity to show educational program  
equivalency without having to take an examination in addition to the NCLEX, but the Board does not agree with  
the comments to entirely remove the CGFNS CP option or the reference to the certification and examinations in  
the rules as the proposed rules include various options to show educational equivalency in addition to using the  
CGFNS CP pathway. The CGFNS CP should remain as one of the options in the rule, as there may be  
applicants who have already completed this pathway or are in the process of completing this pathway for  
licensure in Michigan.  
The Board does not adopt MHA’s comment to allow passing the NCLEX in English as proof of educational  
program substantial equivalency in R 338.10204, in order to sit for the NCLEX. The options to prove  
4
educational program substantial equivalency have already been broadened in the proposed rules to accept  
alternatives in addition to the CGFNS CP. Passing the NCLEX is not proof of educational program substantial  
equivalency. However, it appears that this comment and Henry Ford Health System’s comment requests that the  
rules allow applicants who have attended a program outside of the United States, and who have already taken the  
NCLEX in another jurisdiction, to not be required to repeat the exam again in order to apply for licensure in  
Michigan. Therefore, the Board will modify R 338.10208(1)(c) and R 338.10212(1)(c) to clarify that individuals  
who have graduated from a program outside of the United States, and have already passed the NCLEX in  
another jurisdiction, may apply for licensure in Michigan.  
The Board also modifies the reference in rules R 338.10204, R 338.10208, R 338.10208a, R 338.10210, R  
338.10212, and R 338.10212a, from “CES academic report” to “CES professional report” for consistency with  
the comments to offer a CGFNS credentials evaluation service as one of the evaluations of a substantially  
equivalent educational program. The “academic report” is for college placement, while the “professional report”  
is for licensing.  
R 338.10208 Graduate from non-accredited registered professional nurse education program outside of the United States or  
Canada; graduate from non-board approved program; registered professional nurse program; licensure requirements.  
Rule 208. (1) An applicant for a registered nurse license who graduated from a registered professional nurse education  
program from a country outside of the United States or Canada, shall submit a completed application on a form provided by  
the department, together with the requisite fee, and comply with the following requirements:  
(a) Meets section 16174 of the code, MCL 333.16174, and submit his or her fingerprints to the department of state police to  
have a criminal background check conducted by the department of state police and the FBI.  
(b) If the applicant has not passed the NCLEX-RN examination, the applicant shall establish that he or she meets the  
eligibility requirements to sit for the NCLEX-RN examination set forth in R 338.10204 and must pass the NCLEX-RN  
examination.  
(c)(1) Except as provided in subrulessubrule (3) (2) and (4) of this rule, if the applicant is a graduate of a registered professional  
nurse education program that is located outside of the United States the applicant shall have his or her nursing education reviewed and  
certified by the Certification Program of the CGFNS or its successor agency. Certification from CGFNS is required before receiving  
authorization from the department to take the NCLEX-RN examination under R 338.10204. Information about the certification  
program can be obtained from the CGFNS website at www.cgfns.org. or Canada, has passed the NCLEX-RN examination, and is  
not licensed in another state or is licensed in another state for less than 5 years, he or she shall submit 1 of the following to the  
5
department that shows he or she graduated from a program with substantially equivalent education credentials as a program  
approved by the board:  
(i) A CES professional report from the CGFNS or its successor agency.  
(ii) A certification from the CGFNS CP or its successor agency.  
(iii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from JS&A.  
…
R 338.10212 Graduate of non-accredited nurse education program outside of the United States and Canada; licensed practical  
nurse; licensure requirements.  
Rule 212. (1) An applicant for a practical nurse license who graduated from a nurse education program from a country  
outside of the United States or Canada, shall submit a completed application on a form provided by the department, together  
with the requisite fee, and comply with the following requirements:  
(a) Meet section 16174 of the code, MCL 333.16174, and submit his or her fingerprints to the department of state police to  
have a criminal background check conducted by the department of state police and the FBI.  
(b) If the applicant has not passed the NCLEX-PN examination, the applicant shall establish that he or she meets the  
eligibility requirements to sit for the NCLEX-PN examination set forth in R 338.10210 and shall pass the NCLEX-PN  
examination.  
(1) (c) Except as provided in subrule (2) of this rule, if the applicant is a graduate of a licensed practical nurse education program that  
is located outside of the United States, or Canada, has passed the NCLEX-PN examination, and is not licensed in another state  
or is licensed in another state for less than 5 years, the applicant shall submit 1 of the following to the department that shows  
he or she graduated from a program with substantially equivalent education credentials as a program approved by the board:  
(i) A CES professional report from the CGFNS, or its successor agency.  
(ii) An Evaluation of Foreign Educational Credentials for Boards of Nursing from JS&A.  
(iii) A certification from the NACES or its successor agency.  
…
Rule 338.10404c  
Rule Numbers  
Specialty certification qualifications; clinical nurse specialist.  
Commenter  
Comment  
Section (1)(c)(i)  
Jackson  
Allow for the National Certification Corporation for the Obstetric, Gynecological and Neonatal  
Nursing Specialties to be accepted as a certification organization in R 338.10404c(1)(c)(i).  
6
Rules Committee The Rules Committee does not recommend that the National Certification Corporation for the Obstetric, Gynecological  
Response  
and Neonatal Nursing Specialties be added to the rule as an organization that provides an advanced practice certification.  
However, in the next rule set the Rules Committee would like to consider alternative pathways, including a portfolio  
option, to allow nurses with advanced education and experience to be eligible for specialty certifications.  
Board Response  
The Board does not recommend that the National Certification Corporation for the Obstetric, Gynecological and  
Neonatal Nursing Specialties be added to the rule as an organization that provides an advanced practice  
certification. However, in the next rule set the Board would like the Rules Committee to consider alternative  
pathways, including a portfolio option, to allow nurses with advanced education and experience to be eligible for  
specialty certifications.  
R 338.10404c Specialty certification qualifications; clinical nurse specialist.  
Rule 404c. (1) A specialty certification for a clinical nurse specialist must be granted to a registered professional nurse who satisfies  
all of the following requirements:  
(a) Holds a current and valid license to practice nursing in this state.  
(b) Submits an application for certification as a clinical nurse specialist, on a form provided by the department with the required fee.  
(c) Possesses either of the following:  
(i) An advanced practice certification from either of the following certification organizations, or successor organizations:  
(A) The American Nurses Credentialing Center.  
(B) The American Association of Critical Care Nurses Certification Corporation.  
(ii) If an applicant is unable to take a national certification exam due to graduation from an accredited clinical nurse specialist  
master’s or doctoral nursing program before the development of clinical nurse specialist core competencies and the requirement of 500  
clinical practice hours, he or she may be granted a specialty certification as a clinical nurse specialist based upon submission of a  
portfolio of evidence that demonstrates knowledge and skill competence in the clinical nurse specialist role and population focus. The  
portfolio must include all of the following:  
(A) Transcripts from an accredited master’s or doctoral level educational program in clinical nursing with preparation as a  
clinical nurse specialist.  
(B) Curriculum vitae demonstrating work history in a clinical nurse specialist position before April 9, 2017.  
(C) Three letters of recommendation, including 1 from a clinical nurse specialist with national board certification and 2 letters  
from nursing administrators, nursing supervisors, or advanced practice nurses attesting that the applicant has at least not less than  
3,000 hours of practice as a clinical nurse specialist before April 9, 2017. These letters must provide evidence that the applicant  
7
engaged in practice consistent with the standards for a clinical nurse specialist as described by the National Association of Clinical  
Nurse Specialists (NACNS) in the publication entitled “Clinical Nurse Specialist and Core Competencies” 2010, which is adopted by  
reference. A copy of the standards and requirements is available at no cost from the association’s website at www.nacns.org. A copy  
of the standards and requirements also is available for inspection and distribution at no cost from the Board of Nursing, Michigan  
Department of Licensing and Regulatory Affairs, 611 West Ottawa, Lansing, MI Michigan 48909  
(2) Application for certification as a clinical nurse specialist granted under the criteria set forth in subrule (1)(c)(ii) of this rule is not  
permitted after March 8, 2020.  
8
;