Nebraska Wesleyan University

Nebraska Wesleyan University Nursing 236 – Introduction to Nursing Research

Motivation for Specialty Certification in Nursing PracticeJuly 2005

Motivation Students • Barbara Barr, RN • Pat Jackson, RN • Marva LaGrant, RN • Michelle Newton, RN • Lavon Sanford, RN • Susan Sweat, RN • Jeanette Welch, RN • Leah Wright, RN • Sherry Yeggy-Nail, RN, CCRN

Motivation How the Problem was Identified During preparation to attain magnet status, our institution discovered only 3 of 400 nurses were certified in their respective area. Then the question was posed, “Why are there only 3 nurses that hold specialty certification?” A group of managers proposed that the lack of motivation to achieve specialty certification was based on lack of promotion within the institution and lack of monetary value. Many believe that these specialty certifications provide positive aspects for patients and the institution.

Motivation Problem Statement What motivates nurses to become certified in a specialty area? The purpose of the research is to study the factors that motivate nurses to become specialty certified.

Motivation Literature Review

Motivation According to American Association of Critical-Care Nurse ( 2002), in November of 2002 a Harris omnibus survey was taken in the United States. The results of the survey revealed 96% believed that nurses play in imperative role in the patient’s welfare and their recovery from illness. 73% of the people surveyed said that they were more likely to select a hospital that had specialty certified nurses. Another study conducted in 2001 reported that 92% of managers in the critical care area encourage nurses to become certified, but less than half of hospitals provide financial assistance (New Data Reveals Nurse Certification Key Component of Patient Safety and Recruitment and Retention Programs. (2003). American Journal of Critical Care, 12, 160-164.) AACN recommends that employers support specialty certification to broaden their commitment to safe and quality care and conduct studies to validate that certification helps provide better patient outcomes, retention and increased job satisfaction.

Motivation The AACN conducted a study that was titled “Summary of Findings: Taking the Pulse – Key Influencer Survey”. The research objective was to survey the perceptions of certification among influencers of healthcare. Telephone interviews were conducted with a total of 78 participants. The participants included managers, administrators, legislators, educators, faculty of nursing schools, managed care organizations and AACN ambassadors. Each interview conducted lasted about 15 minutes.

Motivation Perceived Importance and Advantages of Certification(n=78) American Association of Critical-Care Nurses. (2002) Summary of Findings: Taking the Pulse – Key Influencer Survey

Motivation Perceived Importance of Validating Knowledge in Specific Areas“Very Important”(n=78) American Association of Critical-Care Nurses. (2002) Summary of Findings: Taking the Pulse – Key Influencer Survey

Motivation Strategies to Increase Certified Nursing Practice(n=78) American Association of Critical-Care Nurses. (2002) Summary of Findings: Taking the Pulse – Key Influencer Survey

Motivation • Specialty certification for nurses will help to provide protection to critically ill patients by nurses acquiring knowledge and competence. (American Association of Critical-Care Nurses [AACN], 2004). • According to the Association of Perioperative Nurses, their review of literature suggests the benefits of certification include: • Broader range of job opportunities • Challenge • Commitment to professionalism • Job satisfaction (Byrne, M., Valentine, W., Carter, S., 2004.)

Motivation This article’s strength is ease of interpretation. The weakness one could easily identify, would be that the sample population was small. There was no demographical or geographical data obtained, also.

Motivation • Personal achievement and satisfaction • Professional obligation • Validation of knowledge (Association of Perioperative Nurses [AORN], 2004). The American Association of Perioperative Nurses conducted a study that utilized the “Perceived Value of Certification Tool”. All studies using this tool were by survey method. In the initial study, surveys were sent to 400 nurses that held the Certification Nurse Operating Room (CNOR). The response rate was 61%. After minor changes were made the final form was mailed to nurses who were certified (n=1398), non-certified (n=594), and administrators (n=1577).

Motivation Association of Perioperative Nursing. (2004). 79; 4, 825-835.

Motivation “Today, nurses hold more than 410,000 certifications in 134 specialties from 67 certifying organizations, and at least 95 different credentials designate these certifications.” (Cary, A., 2001, p. 44). The methods used in “Certified Registered Nurses: Results of the Study of the Certified Workforce” were mailing surveys to 40, 426 certified nurses. To ensure that each organization was represented equally, the certification institutions with a smaller amount of members would have larger proportions surveyed. Once the survey was distributed, the researchers would not know who the respondents were on the completed forms. The survey consisted of 34 questions. Approximately half of the surveys were returned (48%). The four areas that were surveyed were the personal, professional, career and practice characteristics.

Motivation

Motivation “During the current nursing shortage, retention of experienced, knowledgeable nurses is of critical importance to the success of a healthcare institution.” (Jakubik, L., Grossman, M., Daly-Parker, M., Gaffney, L., Strauss, K., Mars, K. 2004) The Children’s Hospital of Philadelphia, PA developed The Pediatric Medical Nursing Certificate Program (PMNCP) to help retain nurses that want to specialize in pediatrics. They used classroom and a clinical component to help provide the experiences necessary to retain nurses in the pediatric acute care. Retention of these nurses by this method enhance job satisfaction, knowledge and skills, and professional role development. The targeted nurses were those who were experienced in pediatric acute care.

Motivation Jakubik, L., Grossman, M., Daly-Parker, M., Gaffney, L., Strauss, K., Mars, P. (2004). Clinical and Professional Role Development Among Experienced Pediatric Nurses: The Pediatric Nursing Certificate Program. Journal for Specialists in Pediatric Nursing, 9(4), 113-122.

Motivation The PMNCP program was a 6 month multisystem approach that involved classroom and clinical experiences. After the first 36 months of the program an evaluation was performed. Certificate program participants had improved from baseline 86% and non-certificate participants 34% in knowledge scores. Skills scores for the certificate participants had improve 46% and the non-certificate participants 33%. Skill scores were based on the Likert scale 1-5, with 1 being poor and extremely high as 5. The key to success, based on the article, was maintaining management support and the multidisciplinary team. An observation made about this article is, though it does not speak about specialty certification, it does offer data that enhances the ideal that nurses that have the knowledge to obtain certification will improve in their skills and possibly could improve better outcomes for patients.

Motivation In the article “Specialty Certification – More Than Just a Title” a group of nurse managers were surveyed on their perceptions of the value of specialty certification. The American Board of Nursing Specialties (ABNS) performed surveys at exhibits in 2002 at nursing management conferences. A total of 139 surveys were completed. Of theses that were completed the results were placed into three categories: 1) preference of hiring certified versus a non-certified nurse (2) incentives used to promote and recognize specialty certification (3) perceptions about the differences in performance of certified and non-certified nurses.

Motivation The results concluded that nurse managers stated that 86% would hire a certified nurse over a non-certified nurse. Those managers that had never been certified were less likely to hire a certified nurse over a non-certified nurse (82.8%). Only 11% of nurse managers surveyed had more than 50% of staff at their institution certified in a specialty area. In the chart provided on the next slide were the results of the survey responses of nurse managers.

Motivation Stromborg, M.., Niebuhr, B.,Fabrey, L., Muenzen, P., Spence, C., Towers, J., et al. (2005) Specialty Certification – More Than a Title. Nursing Management, 2005, 36(5), 36-46.

Motivation This article does not adequately survey the nurse managers in the United States due to the limited number of participants. Although one can make an assumption based on the statistical information provided that the responses (if taken) from other managers would be similar.

Motivation The accountability of nursing is being demanded by many organizations in healthcare, including third party payers. The public has become more concerned with the care that they receive and question the competence of those that provide that care. A survey was conducted by the Certification Board Perioperative Nurses (CBPN) Research Committee on those nurses that have achieved CNOR certification for perioperative nurses and Certified Registered Nurse First Assistant (CRNFA) credentials. (Gaberson, K., Schroeter, K., Killen, A., Valentine, W., 2003) Based on a tool called “Perceived Value of Certification Tool” the survey was mailed to participants who have already obtained the above mentioned credentials. The participants were selected from the CBPN database and was representative of all geographical regions in the country. Those selected were 2612 CNOR and 138 CRNFA.

Motivation A total of 1398 surveys were collected, about 50%. Only the responses without missing questions were used in the study. Value statements were included in the survey and scored on a Likert scale. For most, the value statements were agreed in support. The only statement that scored less than 50% by participants was the one titled “Increases salary”.

Motivation Gaberson, K., Schroeter, K.,Killen, A., Valentine, W. (2003). The Perceived Value of Certification by Certified Perioperative Nurses. Nursing Outlook 2003, 51, 272-6.

Motivation A strong reliability was found on evaluation of the responses (standardized α = .924). The instrument developed for this survey, the PVCT) is considered psychometrically strong and conceptually consistent. This article is a great tool to use in the future of more surveys. The survey here only consisted of perioperative nurses and we cannot make any assumptions based on the data to correlate other specialty certified nurses and their perceptions of certification.

Motivation Data collected by survey in the article “A Profile of Certification for Pediatric Nurses” discussed the reasons why nurses allow their certification lapse. Surveys were mailed to 275 nurses who had maintained there certification and 317 who had not maintained certification. This survey was only conducted for the pediatric certification through the Pediatric Nursing Certification Board (PNCB). The tool used had a list of potential reasons for not maintaining certification, reasons for maintaining certification. These statements were then ranked by the participant using 1-5 with 5 being most important. The findings between the two groups did not differ significantly in basic RN education. The following table explains the results the characteristics of the sample.

Motivation a = significant difference between groups b = א2 10.633, df = 3, p= .014 c = א2 19.669, df = 1, p = .001 d = א2 10.423, df = 3, p = .015

Motivation The top 5 reasons for lapsed certification were: • Healthcare system does not value certification 58% • Certification exam too expensive 56.8% • No professional benefits for certification 53.4% • Certification has no value in terms of getting promoted 53.4% • Annual costs for certification maintenance prevent participation 50% The top 5 reasons for maintaining certification were: Increases confidence in my knowledge of pediatric nursing care 80.5% Encourages me to earn continuing education to maintain certification 80.5% Is recognized and respected within the healthcare system 60.4 Provides special recognition among my nursing colleagues 58.5% Encourages me to maintain pediatric nursing practice in order to maintain certification 58.5%

Motivation The results of this study that are interesting are that some of the participants that allowed their certification to lapse were seeking higher education. So the results mean that nurses do not always continue certification, but do appear to continue with educational growth. This article is relatively easy to read and presents data in a fashion that is organized. It makes some interesting correlations between lapse of certification and continuing education. The only weakness to this article would be that it does not describe the data in relation to geographical region in is based only on pediatric certification.

Motivation Nurses who obtain specialty certification are more open to family involvement during resuscitative measures and invasive procedures according to Ellison, S. (2003). The study in which appears in the article “Nurses’ Attitudes Toward Family Presence During Resuscitative Efforts and Invasive Procedures” (2003) was conducted using 7 statements that used the Likert scale and 6 open ended questions. Of the six open ended questions that data that was collected was on the following: attitudes, concerns, beliefs and current practice of the individual. Results concluded that “There was a positive correlation between specialty certification and attitudes accepting family presence (r = .216, P < .01).” One might can make the assumption that by obtaining specialty certification the nurse is more knowledgeable and able to communicate easier to the family members.

Motivation Some of the reasons for not allowing family presence would be the lack of knowledge of the family, traumatic experience, too many people in the room and not enough staff to provide support for the family. In conclusion of this article it is stated “Working in an environment with supportive colleagues such as those with higher education and specialized training is more likely to bring about change in behavior.” Education and learning how to develop nurses’ abilities to provide emergency care with the presence of the family is the key to the needs of the families. As time evolves more and more families will be in the room with a loved one, through education and higher learning these nurses will have the tools that they need to assist these family members. This article is exceptional in that it provides statistical data that makes correlations between education and attitudes toward family presence in resuscitative efforts. The only weakness is that this data was collected at only one hospital. Also some of the data interpretation requires statistical background in order to understand the results.

Motivation Representatives at a 3-day conference discussed the problems, consensus and the recommendations on specialty certification (Oncology Nursing Certification Corporation Research Committee and Executive Staff. (1999). Report of a State-of-the-Knowledge Conference on U.S. Nursing Certification. Image: Journal of Nursing Scholarship, 31(1), 51-5. Many questions were posed and discussed. Some of the questions were: • Is nursing certification needed? The answer was yes. Many consider that specialty certification is a standard of practice or should be. The public and managed care look to certifying bodies to provide the standard of care in their respective area. • Who should be responsible for specialty certification? They concluded that the certifying bodies that already provide specialty certification to continue to do so. • Can Collaboration among certification organizations exist? Many certifications are provided by the American Board of Nursing Specialties (ABNS). The does require a BSN to certify under their umbrella. Not all certifying bodies require a BSN.

Motivation • How should certification be measured? Most testing is paper and pencil, usually a multiple choice test. A skills competency has not been required due to cost. • How often should competencies be measured? Some agencies require retesting while others require the accumulation of continuing educational hours. The conference was a meeting place for many specialties to come together and discuss ideas for the future. The weakness of this article is that it is a consensus paper and has no statistical data that supports certification. The article was also published in 1999. The strength of the article reveals that all specialty certifying bodies come to the same conclusion, that certification could provide better patient outcomes based on the specialized knowledge of the nurse.

Motivation Our Plan for Implementing a Specialty Certification Program at Jefferson Regional Medical Center

Motivation The Iowa Model of Evidence-Based Practice to Promote Quality Care is the model that these researchers will follow to implement a Specialty Certification Program for Jefferson Regional Medical Center. Based on this model, there are problem-focused triggers and knowledge-focused triggers. Once there is a trigger, we can follow those triggers and develop and implement our program. We will follow the diagram based on this model.

Motivation Step #1 Our trigger is a knowledge-focused trigger. Our institution is in the process of preparing for Magnet Recognition Certification through the American Nurses Credentialing Center. The 14 forces of magnetism are: • Quality of Nursing Leadership • Organizational Structure • Management Style • Personnel policies and Programs • Professional Model of Care • Quality of Care • Quality Improvement • Consultation and resources • Autonomy • Community and the hospital • Nurses as teachers • Image of Nursing • Collegial Nurse-Physician Relationship • Professional Development

Motivation We are focusing only on a few that deal with specialty certification and the benefits of certification. Through the review of the literature we have established that specialty certification relates to the professional model of care, quality of care, image of nursing, and professional development. We believe that this topic is a priority for the organization based on the fact that Jefferson Regional Medical Center (JRMC) is in preparation for obtaining Magnet Recognition in the near future. The following slides will detail our plan for the institution.

Motivation • Outcomes to be achieved: • Better the quality of care for patients at JRMC as reflected by Press-Ganey scores. • Increase awareness among nurses about specialty certification • Improve ongoing Quality Management data in areas of medication errors, patient complaints, patient outcomes. • Support JRMC’s mission statement: Jefferson Regional Medical Center is committed to providing measurable quality health services in a caring environment which fulfill the needs of our patients, physicians, employers, employees and community. • Vision Statement: Jefferson Regional Medical Center will be widely recognized as the health care leader and referral center of choice for South Arkansas by providing quality health care services in a cost effective manner.

Motivation • Baseline Data • Quality Management data related to quality patient care • Knowledge assessment tool pre-certification • Only 3 specialty certified nurses out of 400.

Motivation • Evidence-Based Guidelines • Practice will be based on the best practice models provided by certifying bodies • Pilot Units • Areas selected will be those that have a specialty certification • Critical Care • Progressive Care

Motivation • Evaluate process and Outcomes • Monitor data from Press-Ganey and Quality Management • Modify practice • Upon completion of the data collected and interpreted make changes necessary to implement the program house-wide. • A continuing assessment of process and outcome data will be conducted. Data on staff perceptions and hospital costs will be assessed at least annually.

Motivation Detailed Plan

Motivation ASSESSMENT: To assess the nursing staff’s perception of specialty certification a tool similar to the Perceived Value of Certification Tool (PVCT). The tool will be e-mailed to all nurses and encouraged to respond on the nursing web site for JRMC. The results will be tallied and posted on the website for all nurses to see and the plans for a Specialty Certification Program at JRMC.

Motivation TEAM: Our team consists of the students in this class who are employed by JRMC. We have reviewed the literature on many issues related to specialty certification on the prior slides. PANEL: A panel of nurses will be formed to select the participants in the program. The panel will consists of 5 members to include a manager, a staff educator, a specialty certified nurse, a member of the Magnet Team and the VP of Nursing. These panel members will be charged with the duty of an approval process that the nurse seeking certification will apply. APPLICANTS: The nurses that seek certification in their area of expertise will create a portfolio to include: years of experience, areas of experience, educational level of nursing, certifications already obtained, certified continuing education hours for the past six months to one year. This portfolio will be submitted for review to the panel. A tool to evaluate the nurses knowledge will provide a pre-certification level. The same tool will be used one year after certification to evaluate a post-certification level of knowledge. Once the review of the portfolio has been completed the nurse will be interviewed by the panel. Upon approval of the candidate, the candidate will sign a letter of commitment to obtain specialty certification. Certification should be obtained within six months after the approval process.

Motivation REIMBURSEMENT and RECOGNITION: The institution will provide half of the examination fees with the application to the certifying body. Upon successful completion of certification the individual will be reimbursed for the amount of the exam fees that they paid once the receipt and completion certificate are submitted. The newly certified nurse will have there name in the Pulse (weekly newsletter) with there newly obtained credentials, under the “Star Performers” section. A specialty certification plaque will be maintained at the main entrance to the hospital and will bear the names of those who have achieved specialty certification status. A specialty certification differential will be added to their pay that will consist of an additional $1.00/hour. The incentive to retain certification status is that the differential will be discontinued if they allow their certification to lapse or move to an area that the credential will not serve the individual or the institution in a positive manner. DATA COLLECTION: Quality Improvement data that continues to be collected will be interpreted at various stages of the implementation. This data will compare the differences in care pre-certification and in increments of post certification at 10%, 20% and 50% of staff obtaining specialty certification. Our goal is to be a realistic goal for specialty certified nurses at our institution, with at least 50% of the nurses obtaining certification.

Motivation Self-Reflection of Project and Critique of Research Utilization

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