Specialty Certification: A Path To Improving Outcomes

Nursing’s social contract reflects our responsibility to govern and regulate our profession. One fundamental way that nursing regulates itself is by ensuring that only individuals who meet minimum qualification standards are licensed to practice nursing. Certification, on the other hand, validates mastery of specialty knowledge beyond the scope of registered nurse (RN) licensure. Although certification extends beyond licensure, both pro-mote safety of health care consumers.Certification promotes professionalism by bolstering commitment and accountability for ongoing professional development and lifelong learning. After achieving certification, nurses are required to recertify at regular intervals, usually every 4 to 5 years. The recertification process involves meeting practice (actual number varies by specialty) and ongoing learning (conferences, academic credits) requirements. Maintaining skills and staying abreast of trends and best practices may not only improve health care outcomes for patients/families and communities but also lead to new career opportunities for certified nurses.As a result, specialty certification achieves multiple purposes. For nurses, certification validates specialized knowledge, skills, and abilities; clarifies roles and responsibilities; provides professional support; and shapes future practice. For organizations, certification improves processes of care, enhances work culture, improves job satisfaction and recruitment/retention, and advances the safety and quality of care.1 But to what extent does certification improve all of these outcomes? This inquiry led to the PICO (patient/population/problem, intervention, comparison, and out-come) question underlying this evidence synthesis: Is specialty certification (I) of critical care nurses (P) associated with better patient, nurse, and organizational outcomes (O) compared with noncertification (C)?The strategy included searching CINAHL. Key words included certification, patient outcomes, nurse sensitive indicators, nurse outcomes, and organizational outcomes. The search was limited to original research in the past 10 years in which the sample included critical care data.Fifteen studies met the criteria to be included. Of these, 1 was a systematic review2 and 14 were descriptive comparative cohorts using cross-sectional,3–9 longitudinal,10,11 or secondary analyses.12–16 Patient, nurse, and organizational outcomes associated with certification are depicted in the Figure.2–14,16 Outcomes reflect samples including high-acuity and/or critical care nurses. Importantly, other certifications were represented in these samples, so reported outcomes have broader application to other nursing specialties. Unit certification proportions are noted where available.For patients, certification was associated with lower rates of complications,8,9 failure to rescue (ie, inpatient deaths following complications), and intensive care unit mortality, and 30-day mortality.2,9,14 More specifically, higher certification rates were significantly related with less need for mechanical ventilation9 and a lower incidence of complications after pediatric cardiac surgery such as cardiac arrest, heart failure, pneumonia, or infection (certification rate 24%).8 In a study of more than 1.2 million surgical inpatients (N = 652 hospitals),14 with every 10% increase in certified nurses with a bachelor of science degree in nursing, the odds of 30-day inpatient mortality decreased by 2%. A similar impact on failure to rescue was found. Thus, certification had no effect alone on mortality and failure to rescue but did when combined with education.Other patient outcomes significantly affected by specialty certification were hospital-acquired conditions. Total fall rates were inversely associated with higher certification rates.2,6,11,13 In one longitudinal study, as certification increased (from 14.6% to 19.3%), total fall rates improved over time; notably 56% of that sample included high acuity/critical care units.11 In another multisite study (N = 4 hospitals) that included unit falls data, it was estimated that with every 1-unit increase in the percentage of certified nurses, total fall rates/1000 patient days decreased by 0.01 to 0.03 (95% CI).6 Similarly, others found a decrease of 0.04 total falls with every 1-unit change in certification across 48 study units.13Hospital-acquired infections were also affected by certification. Rates of central catheter–associated bloodstream infection (CLABSI) lessened when the catheters were inserted by nurses credentialed in the insertion of central catheters.2 Incidences of CLABSI and ventilator-associated pneumonia were lowered by 0.43 and 0.17, respectively, with higher proportions of certified critical care nurses in 4 units (mean certification rates 11.7%10 and 24.1%16). A secondary analysis of 178 surgical intensive care units (SICUs) matched with their respective perioperative units15 showed that SICU CLABSI rates were significantly lower with higher rates of perianesthesia certification (CAPA 20%, CPAN 30.8%) and operating room (CNOR)/first assist (CRNFA) certifications (63%) but not SICU certifications (28.9%).In a large multisite study of 69 hospitals (N = 346 units),12 higher perioperative (CNOR/CRNFA/CPAN) and other specialty certifications were associated with lower occurrence of surgical site infections across colon and hysterectomy procedures. Certification proportions across hospitals were 22% for CNOR/CRNFA, 2.9% for CAPA, 13.5% for CPAN, 34.3% for critical care, and 29.7% for medical/surgical units. In multivariate analysis, however, these associations were small and attenuated to nonsignificance.Certification has also been examined from a patient satisfaction perspective. In one study,2 the patient satisfaction index increased from 14% to 51% as certification rates increased in a 4-year period. An 8% increase in staff with a bachelor of science in nursing also occurred during this timeframe and consequently, education and certification may have had a combined effect on patient satisfaction— similar to the impact of certification and education on mortality and failure to rescue.14For nurses, certification was positively associated with improved knowledge and skills. Certified critical care nurses reported increased competence with 20 skills. Recognizing one’s own abilities and professional competence was the skill with the largest increase after certification.2Overall workplace empowerment was enhanced by certification,2–5 as were many of its 6 structural empowerment-related dimensions, including Certified nurses across 25 intensive care units (certification rate, 17%) in one study5 reported higher empowerment related to resources, information, and support. In different studies,3,4 nurses with a certification from the American Association of Critical-Care Nurses (AACN) or another national certification (51%-53%) reported higher scores on empowerment dimensions of information, and informal/formal power. Greater empowerment was also demonstrated by certified nurses’ reporting more involvement in decisions about staffing.2Finally, certification was associated with higher job satisfaction in 1 study. Job satisfaction increased 14% when certification rates increased from 21% to 50% in a 4-year period.2Organizationally, certification affected intent to leave and, subsequently, turnover and vacancy rates. In 2 studies,2,4 certified nurses reported lower intent to leave their current positions. Nurses who expressed lower intents to leave their current position or the nursing profession had higher empowerment scores. In a study by Fitzpatrick et al,4 AACN-certified nurses were less inclined to leave.Vacancy and turnover rates were inversely associated with certification.2 As Whitehead et al2 suggested, as individual hospitals launch certification campaigns, these may be one of many initiatives influencing organizational outcomes.In this synthesis of level C evidence (Table 1), specialty certification had positive effects on patient outcomes (lower mortality, complications, failure to rescue, falls, and health care–associated infections and higher patient satisfaction), nurse outcomes (greater knowledge/skills, empowerment, and job satisfaction), and organizational outcomes (lower intent to leave, turnover, and vacancies). The effect of certification was in conjunction with higher educational levels for some outcomes like mortality and patient satisfaction. Albeit low-level evidence, many outcomes (see Figure) were also related to other specialty certifications such as oncology, perinatal, and emergency nursing certifications.2,6,11,14,15As patient outcomes are measured at the unit level, a certain proportion of certified nurses may be needed to improve outcomes. The proportion of certified nurses reported in this synthesis ranged from 11.7% to 63%. Such wide variation leads to challenges in interpreting links between certification and outcomes.2 Consequently, the proportion of certified nurses or “dose”—and types of certification—needed to have a positive effect on specific outcomes on various unit types may differ and thus is a key focus for future research.19In addition to dose, many researchers acknowledge challenges of analyzing complex intervening variables1,12,13,19 to show the influence of certification in reducing harm. For example, in a study of surgical outcomes, Boyle and colleagues15 reported that CNOR/CRNFA/CPAN certifications were associated with higher rates of hospital-acquired pressure injury (HAPI). These outcomes occurred in hospitals employing not only more certified nurses, but also with higher case mix indexes and perioperative units with lower practice environment scores. As a result, the impact of certification may have been obscured by acuity factors (eg, systemic disease, complications, specialized/longer surgeries) increasing patients’ risk for HAPI developing, and environmental factors limiting nurses’ autonomous practice to implement evidence-based strategies to prevent skin breakdown during operative procedures.As a result of these challenges, Needleman et al1 advocated a nonlinear framework for credentialing research. This framework includes intertwined pathways depicting the direct or indirect associations of variables between certification and outcomes. These pathways include In viewing certification through this lens, multiple dimensions of empowerment may assist certified nurses in exerting influence on this invisible architecture and ultimately make a difference in their practice environments. For instance, certified nurses may have a positive impact on the characteristics of the culture such as the degree of nurse autonomy, decision-making, and professional development, as well as the quality/supportiveness of nurse-to-nurse, nurse-to-physician, and leadership relationships. Depending on the culture, this architecture could also suppress certified nurses’ autonomy and decision-making, leading to poorer patient and workplace outcomes, such as the previously reported negative association between certification and HAPI.15 Further research is needed to investigate how these pathways interact to create multiple associations and causal pathways that affect outcomes.1,12Certification is recognized as a mark of excellence in the Magnet Recognition Program sponsored by the American Nurses’ Credentialing Corporation. For Magnet designation, organizations must show a plan to increase the proportion of certified nurses over time. Boyle et al20 found that once Magnet status was achieved, hospitals continued to strive to increase nursing competence via specialty certification. If a critical proportion or “tipping point” is needed to observe measurable differences on desired outcomes,2 nurse leaders are urged to focus certification campaigns on the intrinsic and extrinsic rewards of certification, as well as to develop strategies to remove identified barriers to certification (Tables 2 and 3). These campaigns can assist critical care units on their path to the AACN’s Beacon Award for Excellence, which recognizes certification as a key professional development activity.Seeking a specialty credential is a personal decision influenced by many factors. Wherever you might be in your journey, I would like to close by sharing my journey with certification: