Certification A Benchmark for Critical Care Nursing Excellence

Every day the delivery of health-care becomes more complex as new treatments are discovered and new technologies for diagnosing and treating disease are developed. Adding to this challenge, today’s patients often have multiple physical and psychosocial problems. In practically every setting, patients are older and sicker than before.1 These factors blend to create an ever-increasing demand for knowledgeable and skillful care providers. The depth and breadth of knowledge required are only partially satisfied by the entry-level nursing education provided by most, if not all, nursing schools. The sheer volume of information to be learned is staggering.To better meet the needs of today’s patients, nurses and other health professionals often seek additional education and validation of their clinical expertise. This acquisition of knowledge can take several forms. Additional formal academic preparation often includes master’s degrees, post-master’s training, and doctoral degrees. After completion of these programs, individuals may be required to successfully pass a certification examination to obtain state licensure in advanced practice.A less formalized, but equally important, validation of knowledge, professional skills, and clinical expertise is specialty certification. Requirements for specialty certifications vary, but all include a practice component and an identified body of required knowledge or testing blueprint. In this article, we discuss some of the reasons why nurses pursue certification, the current status of the certification as described in recent studies, and some recommendations for the future. Findings from the 2004 National Critical Care Survey2 conducted by the American Association of Critical-Care Nurses (AACN) are highlighted.Certification is defined as a process by which a nongovernmental agency validates an individual’s knowledge related to a specific area of practice. This process is based on certain predetermined standards.3 The focus is evidence-based practice and the application of clinical experience.4To ensure that certification reflects current, real-world, high-quality practice, the National Commission for Certifying Agencies set forth certain basic requirements for all certification examinations. To receive accreditation, a certifying body must demonstrate that its examinations are based on current job analyses as well as on accepted testing and measurement principles.5 This requirement means that testing must reflect current practice in the specialty and must measure specified aspects of this practice appropriately.One of the most commonly cited reasons for supporting certification is to protect the public. The primary method of ensuring public safety is licensure. By administering and updating the National Council Licensure Examination for registered nurses (NCLEX-RN), the National Council of State Boards of Nursing ensures the competency and knowledge level of nurses entering practice. Successful completion of this test is the basis for licensure in every state.6 To ensure continuing safety of patients, the Institute of Medicine has recommended that healthcare providers be reevaluated and relicensed periodically.7 No uniform method is currently in place for reevaluating providers. In response to the report from the Institute of Medicine, the AACN published a white paper, Safeguarding the Patient and the Profession: The Value of Critical Care Nurse Certification,6 in which it proposed that specialty certification met the recommendation for ensuring continued competency. The link between certification and safety of patients is reinforced by the research finding that nurses who had been certified for 5 years or less reported that they made fewer errors in caring for patients than the overall group of certified nurses who responded reported.8Beyond ensuring basic safety, certification is often thought to promote quality care. Although certification has been touted as improving quality, the data supporting this claim are scant and mixed.9–11 However, some reports are encouraging. Redd and Alexander10 examined the performance of certified nurses and found that supervisors rated certified nurses significantly higher than noncertified nurses on the parameters of “teaching/collaboration” and “planning/evaluation.” Additionally, at Deaconess Hospital (Evansville, Ind), where CCRNs hold key coordinator positions on the code blue teams, the hospital performs better than the national benchmarks on 6 code-related indicators.12Indicators of quality in health-care have become increasingly of interest to consumers in recent years. Today, it is not unusual to see hospital morbidity and mortality statistics published in newspapers. In addition, the Centers for Medicare and Medicaid Services publish key indicators of hospitals’ performance on the Centers’ Web site to make this information readily available to the public.13 Morbidity, mortality, and scores on performance indicators are objective pieces of evidence that help describe the quality of care given in specific hospitals.Another objective indicator of interest to the public is awards that institutions receive for excellence. Two such programs are the Beacon Award from AACN14 and Magnet recognition from the American Nurses Credentialing Center.15 Appropriately, both of these awards have criteria that address certification.14,15Consumers are also interested in methods of determining the quality of their caregivers. According to the American Board of Nursing Specialties, specialty nursing certification is the main criterion used by the public to recognize quality nursing care.16In a study conducted by AACN and published in 2002, 3 of 4 survey participants indicated that they would be more likely to choose a hospital that employed a high percentage of certified nurses.17 With today’s emphasis on consumer-driven healthcare, both at the grass roots level, and from state and national legislatures, it is not hard to imagine that hospitals and other healthcare entities would use statistics like the numbers of certified nurses to attract potential patients.A movement is under way within nursing to improve the stature of the profession. A major component of this initiative is to increase the educational requirements for advanced practice nurses, but another component is to encourage certification. The stated mission of the AACN Certification Corporation is to provide “comprehensive credentialing for nurses to ensure their practice is consistent with established standards of excellence in caring for acute and critically ill patients and their families.”3 Other nursing certifying bodies have similar goals.18–20According to the latest statistics, as of the year 2000, nurses in the United States and Canada had attained 410000 certifications representing 134 nursing specialties. At that time, at least 67 certifying organizations offered 95 different designated credentials.21 The AACN has been on the forefront of certification efforts since 1975, when it founded the AACN Certification Corporation. Since the first CCRN certification examination was given in 1976, the number of neonatal, pediatric, and adult CCRNs has grown to approximately 40000.3The AACN Certification Corporation has also led the way in developing new certifications as practice expands and differentiates. Today, the AACN Certification Corporation offers 3 specialty examinations and 2 subspecialty certifications (Table 1). The CCNS examination offers certification to clinical nurse specialists who care for acute and critically ill patients. The PCCN program offers certification for nurses in progressive care settings. The newest additions, the subspecialty examinations, credential nurses who already have at least 1 specialty certification, such as CCRN or CCNS, and wish to demonstrate more focused expertise in caring for cardiac medical patients (CMC), or cardiovascular surgical patients (CSC). In 2007, the AACN Certification Corporation will offer certification for acute care nurse practitioners.3As part of its 2004 National Critical Care Survey, AACN examined support for national certification in healthcare facilities and in critical care units.2 Study participants included administrators and nurses from 120 healthcare institutions representing small facilities (50 or more beds) to large academic and urban hospitals (mean 217 operating beds). From this pool of 120 hospitals, nurses from 300 critical care units were surveyed. The critical care units represented included intensive care units (53%), progressive care units (30%), postanesthesia care units (10%), and other types of units (4%).2 (Three percent did not respond to the question about the type of unit.2)The primary purpose of this national survey, the largest of its kind, was to provide essential information on clinical practice, regulations affecting nurses and patients’ care, and work-place issues.2 Data from this survey were intended to be used as benchmarks against which the performance of other individual healthcare facilities or critical care units could be measured. Incorporated in this survey were questions pertaining to national certification. The study elicited information on certification in the following 6 areas2:Financial support for certification was greatest for the certification examination fees; 6 of 10 units paid full or partial costs for the tests2 (Table 2). Only 53% of units reported paying for part or all of costs for certification review courses.2 Interestingly, the data indicated that large units (≥30 beds) were less likely to pay for certification review courses than were small to midsized units.2 Although this issue was not examined in the study, the larger units might have had the resources to provide internal review courses. Successful completion of the certification examination was required for monetary assistance in 50% of all units surveyed.2 Survey results also showed that 43% of units reimbursed employees for recertification. The group most likely to receive compensation for recertification was intensive care nurses (52%), whereas only 34% of progressive care nurses received money to recertify.2 Other types of financial support included paid time off for certification preparation or test taking.2The final area explored in the study was the use of bonus or salary differential as support for certification. A third (31%) of responding units rewarded certified nurses with a bonus (65% did not offer a bonus, and 4% did not respond to the question). Of note, small or suburban hospitals were more likely to use this form of acknowledgment than were large, urban, or rural institutions (Figure 1).2 Twenty-one percent of all types and sizes of units offered a salary differential for certification; however, the amount of the differential varied widely2 (Figure 2).Even though only a little more than half of the units and facilities surveyed offered any monetary compensation for certification, about three quarters of the units surveyed recognized their certified nurses in some manner.2 Most commonly, facilities recognized certification by public acknowledgment (Table 3). Urban, rural, and academic medical centers were the most likely to use this method.2 Suburban (63%) and rural (53%) hospitals recognized certified nurses by displaying their specialty credential on their name badges.2Despite the relative lack of financial benefits tied to certification, many acute and critical care nurses still become credentialed. In the national survey, participants from 78% of units indicated having certified nurses.2 The median reported percentage of unit staff nurses holding certification was 10%. However, the overall mean percentage of certified staff was 17%.2 Sixty percent of units represented in the study had staff nurses who had a CCRN credential2 (Figure 3). Not surprisingly, the highest concentration of CCRNs was reported in intensive care units. CCRNs were also more prevalent in urban and suburban hospitals.2Nurses also may seek certification to obtain recognition as a clinical expert, for their personal growth, or for career advancement.8,10,12,22 In Cary’s study8 of certified nurses, 39% of respondents indicated that recognition as an expert was one of the benefits they received. Cary also found that a large percentage (77%) of certified nurses experienced personal growth.8 In fact, this perceived benefit was so important that in an AACN-commissioned focus study on CCRNs, personal satisfaction was cited as the most important reason for becoming a CCRN.22 In other studies, certified nurses also reported being more professionally satisfied8 and scored higher than non-certified nurses scored on measures of self-esteem.10 Career advancement, including promotion up the clinical ladder, was also cited as a benefit of certification.8,12Hospitals have also used certification as a mechanism for improving recruitment and retention. A work-force of certified nurses is a mark of excellence that provides a competitive advantage for hospitals and can be used as a marketing tool for the institution.12 The value of certification can be incorporated into the hospital’s recruitment and retention plan and can be clearly reflected in its classified advertisements and organizational Web site. Now more than ever, recruiting and retaining the most qualified and professional workforce is a matter of survival for hospitals.6As an illustration of how certification can improve recruitment and retention, one hospital increased the number of bedside CCRNs from 4 in 2000 to 34 in 2004 by initiating a CCRN certification campaign.12 This hospital now reports that it has more CCRNs than any facility in the region, and this information is used in the institution’s recruitment materials.12 This same hospital reports retaining 96% of their certified nurses for 1 year after the CCRN drive. The long-term impact of certification, however, has yet to be fully determined.12 Further research is needed to confirm the contribution of certification to recruitment and retention.Because of the many perceived and documented benefits of certification, many hospitals and other institutions have developed strategies to encourage nurses to become certified. To provide financial support for the CCRN drive at one hospital, nurse managers, the nursing director, and other nurse leaders developed a grant proposal that was presented to the hospital’s foundation. Funds were granted for this project and a subsequent drive to certify medical-surgical nurses. In addition, nursing certification is recognized as a factor to consider in the clinical career ladder at this institution.12 Another unique recognition mechanism is the certified nurse “Wall of Fame” that is set up during national nurses’ week.12At our institution, Georgetown University School of Nursing and Health Studies, certification is used as a “stepping-stone for success.” Acute care nurse practitioner (ACNP) and critical care clinical nurse specialist (CCNS) faculty at the school have embraced the notion of “walking the talk” for nursing excellence through certification. The value of certification is demonstrated by the program’s faculty; all faculty members have multiple certifications, including ACNP, CCNS, CCRN, PCCN, family nurse practitioner (FNP), and adult nurse practitioner (ANP). More importantly, graduate students are expected to be double certified as well.During admission of ACNP/CCNS graduate students, all noncertified nurses are advised about the importance of validating their knowledge, professional skills, and experience in caring for the most vulnerable patients in the most complex and unstable conditions. Such validation is particularly stressed for students entering ACNP and/or CCNS programs from accelerated programs in which they earned a bachelor of science in nursing as a second degree and from direct-entry programs, because these students may have little or no clinical experience before their acceptance to the Georgetown program.Because validating competence is a top priority for ACNP and CCNS faculty at Georgetown, a certification “path for success” was designed. All students are expected to obtain a nationally recognized certification before starting their ACNP or CCNS clinical rotations. During the program of graduate study, students and their faculty members sign a learning agreement to ensure timely completion of this goal. Access to certification review resources and study groups is provided. This path has been valuable for students for successfully obtaining certification in their chosen specialties. In addition, it provides a solid foundation for their ACNP/CCNS clinical didactic courses. Such credentials as CCRN, PCCN, certified emergency nurse (CEN), and/or certified neurological nurse (CNRN) help close the gap when providers or preceptors question students’ experience and clinical competence in critical care nursing. Students, teachers, and prospective employers easily recognize that those “extra letters” behind the students’ names help validate personal mastery of specialized knowledge and professional skills.Another value of the Georgetown model is that it fosters students’ confidence “to mentor others.” Graduate students often serve on practice councils in their units and encourage their colleagues by saying, “If I can do it, you can too.” Such encouragement has contributed to an increase in the numbers of CCRNs in many of the local hospital’s critical care units.In addition, certified practice is a critical element evaluated in the application for the AACN Beacon Award, which recognizes and rewards excellence in critical care nursing.14 Many Georgetown graduate students have decided to lead Beacon application groups in their intensive care units as their scholarly projects. In summary, requiring ACNP and CCNS students to obtain certification before beginning their clinical rotations is a novel approach to ensuring a baseline level of excellence among students entering intense and rigorous clinical rotations. Preceptors for George-town students often remark that the ACNP and CCNS students are exceptional when compared with students from other similar programs.This approach is also proving to be an important indicator of success for passing the ACNP and CCNS national board examinations. The ACNP and CCNS programs have high pass rates. Former students often remark that they felt well prepared for their advanced practice certification examination. Although many factors contribute to this sentiment, the faculty think that taking an initial certification examination during the program while being mentored through the process significantly increases the comfort and expertise of students in taking this form of test.The final bonus of this initiative is to the patients and the hospitals where these students work while completing their studies and where they will work in the future. By taking and passing a certification examination, the students have all established that they have what it takes to be excellent healthcare providers. The personal satisfaction and increased confidence they experience assists them in their and scholarly they to demonstrate their excellence their as they become some of the most advanced practice nurses in the and healthcare many in today’s and in the future. and high-quality care. The public and healthcare bodies to the indicators of quality so that care can be evaluated more of these indicators is the number of certified health professionals within an Although some data link certification and high quality, more research is needed in this Further of the link between high quality, safety, and certification drive efforts to support and encourage more nurses and other health professionals to become National Critical Care Survey that support for certification but is in no way finding was that of the nurse surveyed and their staff nurses’ efforts in certification. This support was in all units surveyed.2 Although the survey did not why support among nurse was so one can that these perceived that having a certified nursing staff some such as those for certifying CCRNs, and current accepted and national as part of the defined body of knowledge to be By examination these programs offer a mechanism for nurses to what expert practice. the certification process can be used as a tool to mentor staff preparation and study for completion of certification examinations improve an individual’s to care for acute and critically ill patients. certified staff members are better prepared to care for their patients, the quality of care within the unit This is by national quality such as Magnet status for and the Beacon for which consider percentage of certified staff as an indicator of certification is a Nurses job and financial as well as more expert providers and may them for also a valuable marketing tool to attract new nurses and patients. is the patients, however, who receive the most benefit from having certified nurses care for because certification fosters safety and quality of care. Although more research is needed to the between quality, safety, and certification, clearly all nurses in the certification process so that certification becomes the than the for excellence in critical care.