qualitative critique

SPECIALTY CERTIFICATION: A PATH TO IMPROVING OUTCOMES By Margo A. Halm, PhD, RN, NEA-BC

©2021 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2021569

Clinical Evidence Review A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. We welcome letters regarding this feature and encourage the submission of questions for future review.

N ursing’s social contract reflects our responsibility to govern and regulate our profession. One funda-

mental way that nursing regulates itself is by ensur-

ing that only individuals who meet minimum qualification

standards are licensed to practice nursing. Certification,

on the other hand, validates mastery of specialty knowl-

edge 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 certifi-

cation, 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) require-

ments. 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 respon-

sibilities; 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 spe-

cialty certification (I) of critical care nurses (P) associated

with better patient, nurse, and organizational outcomes

(O) compared with noncertification (C)?

Method The strategy included searching CINAHL. Key words

included certification, patient outcomes, nurse sensitive indica- tors, 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.

Results Fifteen studies met the criteria to be included. Of these,

1 was a systematic review2 and 14 were descriptive compar-

ative 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.

Patient Outcomes 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 mechani-

cal 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 hos-

pitals),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

About the Author Margo A. Halm is associate chief nurse executive, nursing research and evidence-based practice, VA Portland HealthCare System, Portland, Oregon.

Corresponding author: Margo A. Halm, PhD, RN, NEA-BC, VA Portland HealthCare System, 3710 SW US Veterans Hospital Road, Portland, OR 97239 (email: [email protected]).

156 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2021, Volume 30, No. 2 www.ajcconline.org

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2021, Volume 30, No. 2 157

alone on mortality and failure to rescue but did

when combined with education.

Other patient outcomes signifi cantly affected by

specialty certifi cation were hospital-acquired condi-

tions. Total fall rates were inversely associated with

higher certifi cation rates.2,6,11,13 In one longitudinal

study, as certifi cation 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 certifi ed

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 certifi cation across 48 study units.13

Hospital-acquired infections were also affected

by certifi cation. 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 propor-

tions of certifi ed critical care nurses in 4 units (mean

certifi cation 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 signifi cantly

lower with higher rates of perianesthesia certifi cation

(CAPA 20%, CPAN 30.8%) and operating room

(CNOR)/fi rst assist (CRNFA) certifi cations (63%)

but not SICU certifi cations (28.9%).

In a large multisite study of 69 hospitals

(N = 346 units),12 higher perioperative (CNOR/

CRNFA/CPAN) and other specialty certifi cations

were associated with lower occurrence of surgical

site infections across colon and hysterectomy pro-

cedures. Certifi cation proportions across hospitals

Figure Outcomes associated with high acuity and critical care specialty certifi cation. Illustration by Lynn Kitagawa, MFA, Medical Illustrator, VA Portland Healthcare System, Portland Oregon.

NU RSE

OUTCOMES

PA TIE

NT OUTCOMES

Improved knowledge/

skills (1 study)

Lower complications

(3 studies)

Lower falls (4 studies)

Lower health care–associated

infections (5 studies)

Higher patient satisfaction

(1 study)

Lower failure- to-rescue (1 study)

Heightened empowerment

(5 studies)

Higher job satisfaction

(1 study)

Lower failure- to-rescue (1 study)

Higher patient satisfaction

(1 study)

Lower complications

(3 studies)

Lower falls (4 studies)

Lower health care–associated

infections (5 studies)

O R

G AN

IZATION A L

OUTCOME S

Lower intent to leave position (2 studies)

Lower nursing turnover (3 studies)

Lower nursing vacancies (2 studies)

Lower mortality (6 studies)

158 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2021, Volume 30, No. 2 www.ajcconline.org

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.14

Nurse Outcomes For nurses, certification was positively associated

with improved knowledge and skills. Certified criti-

cal care nurses reported increased competence with

20 skills. Recognizing one’s own abilities and pro-

fessional competence was the skill with the largest

increase after certification.2

Overall workplace empowerment was enhanced

by certification,2-5 as were many of its 6 structural

empowerment-related dimensions, including

• Opportunities to increase knowledge/skills; • Resources such as materials and time to influ-

ence practice changes;

• Information to expand specialty knowledge and increase effectiveness in the workplace;

• Support from feedback and guidance from leaders and peers;

• Informal power from developing communica- tion and information channels with leaders, peers,

and individuals in other groups inside and outside

the organization; and

• Formal power derived from personal character- istics like adaptability and creativity in decision-making,

as well as visibility and involvement in unit and

organizational goals.17

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 certifi-

cation 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.2

Finally, 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.2

Organizational Outcomes Organizationally, 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 asso-

ciated with certification.2 As Whitehead et al2 suggested,

as individual hospitals launch certification campaigns,

these may be one of many initiatives influencing

organizational outcomes.

Recommendations for Practice 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 out- comes (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

Level Description

Table 1 American Association of Critical-Care Nurses evidence-leveling systema

a From Peterson et al,18 with permission. https://www.aacn.org/clinical-resources/ practice-alerts/aacn-levels-of-evidence

A Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment (including systematic review of randomized controlled trials)

B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment

C Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

D Peer-reviewed professional and organizational standards with the support of clinical study recommendations

E Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations

M Manufacturer’s recommendation only

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2021, Volume 30, No. 2 159

oncology, perinatal, and emergency nursing certi-

fications.2,6,11,14,15

As 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.19

In addition to dose, many researchers acknowl-

edge 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 employ-

ing 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 path-

ways depicting the direct or indirect associations of

variables between certification and outcomes. These

pathways include

• The nurse performance pathway, whereby certi- fied nurses use their expertise to directly influence

the outcomes of patients under their care;

• The work organization pathway, whereby certi- fied nurse’s offer secondary benefits to the work-

place and thus to patients not under their care; and

• The invisible architecture pathway or the culture of the unit and organization that certified nurses navi-

gate to extend benefits of their expertise.

In viewing certification through this lens, multi-

ple dimensions of empowerment may assist certified

nurses in exerting influence on this invisible architec-

ture 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.1,12

Certification is recognized as a mark of excellence

in the Magnet Recognition Program sponsored by the

American Nurses’ Credentialing Corporation. For Mag-

net 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 cam-

paigns on the intrinsic and extrinsic rewards of certi-

fication, 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.

Table 2 Value of certificationa

Intrinsic: personal incentives

Enhances feelings of personal accomplishment

Provides personal satisfaction

Validates specialized knowledge

Indicates professional growth

Indicates attainment of a practice standard

Provides evidence of professional commitment

Provides professional challenge

Enhances professional credibility

Enhances personal confidence in clinical abilities

Indicates level of clinical competence

Provides evidence of accountability

Enhances professional autonomy

Promotes peer recognition

Promotes employer recognition

Promotes recognition from other health care professionals

Increases consumer confidence

Advances the profession

Increases salary

Heightens marketability

Extrinsic: professional incentives

a Based on information from Whitehead et al,2 Fitzpatrick et al,3 McLaughlin and

Fetzer,21 Messmer et al,22 and Van Wicklin et al.23

160 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2021, Volume 30, No. 2 www.ajcconline.org

Seeking a specialty credential is a personal deci-

sion influenced by many factors. Wherever you might

be in your journey, I would like to close by sharing

my journey with certification:

Early in my career, I was fortunate to be

exposed to the AACN, where I learned

about CCRN status. As a staff nurse practic-

ing in a challenging SICU, I was intrigued

about how CCRN certification could

enhance my practice. I obtained the

Core Curriculum, attended a review course, and studied with fellow nurses

seeking certification. What I gained from

getting certified was a stronger knowledge

base of critical care nursing—from dis-

eases and conditions to assessment

techniques to nursing and medical inter-

ventions. The main intrinsic reward I

experienced from expanding my expertise

was the confidence boost in my abilities as

a critical care nurse. That was 1987. Look-

ing back, I can see that certification was

my path to professional growth, lifelong

learning, and the ability to make a differ-

ence. As a CCRN, I gained access to an

invaluable network of colleagues, not to

mention the current science- and evidence-

based tools and guidelines to advance

practice in my role as a critical care clini-

cal nurse specialist (CNS). I proudly held

the CCRN certification for 20 years. It

was a catalyst for my CNS (ACNS-BC)

and now nurse executive (NEA-BC) certi-

fications. Indeed, I can say . . . becoming

certified was one of the best investments

I’ve made to strengthen my practice—

ultimately feeding a fulfilling career.

FINANCIAL DISCLOSURES None reported.

REFERENCES 1. Needleman J, Dittus RS, Pittman P, Spetz J, Newhouse R.

Nurse credentialing research frameworks and perspectives

for assessing a research agenda. NAM Perspect. Published August 21, 2014. doi:10.31478/201408d

2. Whitehead L, Ghosh M, Walker DK, Bloxsome D, Vafeas C, Wilkinson A. The relationship between specialty nurse certi- fication and patient, nurse and organizational outcomes: a systematic review. Int J Nurs Stud. 2019;93:1-11.

3. Fitzpatrick JJ, Campo TM, Lavandero R. Critical care staff nurses: empowerment, certification, and intent to leave. Crit Care Nurse. 2011;31(6):e12-e17. doi:10.4037/ccn2011213

4. Fitzpatrick JJ, Campo TM, Graham G, Lavandero R. Certifi- cation, empowerment, and intent to leave current position and the profession among critical care nurses. Am J Crit Care. 2010;19(3):218-226.

5. Krapohl G, Manojlovich M, Redman R, Zhang L. Nursing spe- cialty certification and nursing-sensitive patient outcomes in the intensive care unit. Am J Crit Care. 2010;19(6): 490-498.

6. Coto JA, Wilder CR, Wynn L, Ballard MC, Webel D, Petkunas H. Exploring the relationship between patient falls and levels of nursing education and certification. J Nurs Adm. 2020; 50(1):45-51.

7. Hickey PA, Gauvreau K, Curley MA, Connor JA. The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States. J Nurs Adm. 2013;43(12):637-644.

8. Hickey PA, Gauvreau K, Porter C, Connor JA. The impact of critical care nursing certification on pediatric patient out- comes. Pediatr Crit Care Med. 2018;19(8):718-724.

9. Fukuda T, Sakurai H, Kashiwagi M. Impact of having a certi- fied nurse specialist in critical care nursing as head nurse on ICU patient outcomes. PLoS One. 2020;15(2):e0228458. doi: 10.1371/journal.pone.0228458

10. Boev C, Xue Y, Ingersoll GL. Nursing job satisfaction, certifi- cation and healthcare-associated infections in critical care. Intensive Crit Care Nurs. 2015;31(5):276-284.

11. Boyle DK, Cramer E, Potter C, Staggs VS. Longitudinal asso- ciation of registered nurse national nursing specialty certifi- cation and patient falls in acute care hospitals. Nurs Res. 2015;64(4):291-299.

12. Bergquist-Beringer S, Cramer E, Potter C, Stobinski JX, Boyle DK. Exploring the relationship between nursing spe- cialty certification and surgical site infections. J Nurs Adm. 2018;48(7/8):400-406.

13. Kendall-Gallagher D, Blegen MA. Competence and certifica- tion of registered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18(2):106-113.

14. Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse specialty certification, inpatient mortality, and failure to rescue. J Nurs Scholarsh. 2011;43(2):188-194.

15. Boyle DK, Cramer E, Potter C, Gatua MW, Stobinski JX. The relationship between direct-care RN specialty certification and surgical patient outcomes. AORN J. 2014;100(5):511-528.

16. Boev C, Xia Y. Nurse-physician collaboration and hospital- acquired infections in critical care. Crit Care Nurse. 2015; 35(2):66-72.

17. Kanter R. Men and Women of the Corporation. 2nd ed. Basic Books; 1993.

18. Peterson M, Barnason S, Donnelly B, et al. Choosing the best evidence to guide clinical practice: application of AACN levels of evidence. Crit Care Nurse. 2014;34(2):58-67.

19. Boyle DK. Nursing specialty certification and patient out- comes: what we know in acute care hospitals and future directions. J Assoc Vasc Access. 2017;22(3):137-142.

20. Boyle DK, Gajewski BJ, Miller PA. A longitudinal analysis of nursing specialty certification by Magnet® status and patient unit type. J Nurs Adm. 2012;42(12):567-573.

21. McLaughlin A, Fetzer SJ. The perceived value of certification by Magnet® and non-Magnet nurses. J Nurs Adm. 2015; 45(4):194-199.

22. Messmer PR, Hill-Rodriguez D, Williams AR, et al. Perceived value of national certification for pediatric nurses. J Contin Educ Nurs. 2011;42(9):421-432.

23. Van Wicklin SA, Leveling ME, Stobinski JX. What Is the per- ceived value of certification among registered nurses? A systematic review. J Nurs Scholarsh. 2020;52(5):536-543.

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362- 2050 (ext 532); fax, (949) 362-2049; email, [email protected].

Table 3 Common perceived barriers to certificationa

Barrier

Lack of expectation or support of certification as a professional development goal

Time to study and be involved in professional activities

Access to certification review materials or courses

Cost of examinations and fees for renewal and continuing education requirements

Inadequate recognition a Based on information from McLaughlin and Fetzer.21

Copyright of American Journal of Critical Care is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.