Skip Navigation LinksHome > January/March 2011 - Volume 22 - Issue 1 > Best Practices in Creating a Culture of Certification
AACN Advanced Critical Care:
doi: 10.1097/NCI.0b013e3182062c4e
Symposium: the Value of Certification

Best Practices in Creating a Culture of Certification

Fleischman, Rhonda K. RN, MSN, CNS, CCRN-CMC; Meyer, Laura RN, MS; Watson, Christine RN, BSN, CCRN

Section Editor(s): Kaplow, Roberta Symposium Editor

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Author Information

Rhonda K. Fleischman is Cardiac Care Unit Clinical Education Specialist, Aultman Hospital, 2600 6th St SW, Canton, OH 44710 (rfleischman@aultman.com).

Laura Meyer is Clinical Manager Critical Care, Portland VA Medical Center, Portland, Oregon.

Christine Watson is Pediatric Intensive Care Unit Clinical IV Nurse—Education Track, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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Abstract

Certification is the criterion standard of professional practice, distinguishing excellence in nursing care, mastery of knowledge, skills, and abilities beyond the scope of professional licensure. It is the validation of an individual nurse's qualifications for practice in a defined area. Becoming certified is a personal and professional commitment that demonstrates the value that the individual nurse places on higher standards of practice and lifelong learning. The American Association of Critical-Care Nurses (AACN) Beacon Award for Excellence, Magnet Recognition Program, and Malcolm Baldrige National Quality Award all recognize certification as a key component of nursing excellence in specialty practice. Both the general public and nurse professionals increasingly recognize the need for practice on the basis of evidence to provide safe, quality patient care. In today's rapidly changing and complex health care delivery system, certification is becoming the standard by which bedside practice and the impact of nursing care on patient outcomes are measured. This article will provide a review of current best practices in creating a culture of certification, including the journey of 3 hospitals selected as the 2010 Best Practice Roundtable presentations at the AACN National Teaching Institute.

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Value of Certified Practice: A Review

Certification is the criterion standard of professional practice, distinguishing excellence in nursing care, mastery of knowledge, skills, and abilities beyond the scope of professional licensure. It is the validation of an individual nurse's qualifications for practice in a defined area.1 The body of literature relating certified practice to outcomes for patients, systems, and nursing is growing. The American Nurses Credentialing Center identifies certification as a means toward the advancement of nursing professionalism, higher standards of care, and better patient outcomes. The American Nurses Credentialing Center further cites 8 organizational and professional reasons for supporting nurse certification (Table 1).2,3

Table 1: Reasons for...
Table 1: Reasons for...
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Evidence from studies of the effects of certification on nurses identifies 3 key findings: an increased confidence in a nurse's abilities, earlier intervention to prevent problems, and more nurse/physician collaboration.4 A review of the literature and perceived effects of specialty nursing certification by Wade5 revealed that the majority of studies conducted in the past 2 decades found certification to be positively associated with nurses' job satisfaction, a sense of empowerment, and a sense of collaboration. This review further demonstrated an association between certification and nurses' perception of patient satisfaction and patient reports of satisfaction.5 Through autonomy over practice and increased clinical expertise, certification provides nurses with the means to practice in a way that can improve patient outcomes.

In 2002, the American Association of Critical-Care Nurses (AACN) released a white paper, Safeguarding the Patient and the Profession: The Value of Critical Care Nurse Certification, outlining the benefits of specialty nursing certification for the public, employers, and nurses.6 Other specialty organizations have developed similar position papers and reported studies related to certified practice.79 The effects of certification on nurse-sensitive patient outcomes have been positively identified in recent literature and practice guidelines including the relationship between certification, increased knowledge, and improved patient management.1012

According to a Harris poll, consumer awareness that nurses can be certified is high, finding nurses to be the most recognizable certified professionals.13 Americans surveyed identified continuing education for nurses caring for critically ill patients to be very important and preferred hospitals that employ nurses with specialty certification. This awareness has made it increasingly important to assure the public that nurses are competent in providing safe, quality care.13

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Creating a Culture: Common Themes

Merriam-Webster defines culture as a set of shared attitudes, values, goals, and practices that characterize an institution or an organization.14 A culture of certification promotes and supports certified nursing practice. Several themes that identify effective strategies in developing a successful culture supportive of certified practice have emerged from the literature. Common incentive strategies focus on financial support from employers, promotions, recognition, and peer support.15,16 A compilation of certification initiatives from across the country including best practice highlights from National Teaching Institute (NTI) certification roundtable presentations is available on the AACN Web site.17 Five themes emerge from this valuable resource for units seeking best practices in creating a culture of certification (Table 2).

Table 2: AACN Best P...
Table 2: AACN Best P...
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2010 Certification Best Practices

In the fall of 2009, AACN posted a call for abstracts of best practice strategies in promoting and creating a culture of certification. The chosen abstracts were presented at the 2010 NTI Certification Roundtable session in Washington, DC. These roundtable experiences offered NTI participants not only 3 professional best practice presentations but also the ability to discuss certification. This approach provided an opportunity for participants to learn not only from presenters but also from nurses around the country who are struggling with many of the same barriers and experiences. In addition, innovative strategies in promoting critical care specialty certification from around the country were revealed.

The 3 best practice abstracts selected for the 2010 NTI Certification Roundtable represent a broad range of both organizational and professional perspectives in approaching and developing successful strategies in creating a culture of certification. Organizationally, the presentations discussed the experience of 2 different adult critical care units. Aultman Hospital's cardiac care unit (CCU) and the medical-surgical critical care unit of the Portland Veterans Administration Medical Center (PVAMC) depict journeys through the professional lens of a clinical nurse specialist (CNS) and a nurse manager. In addition, The Children's Hospital of Philadelphia (CHOP) depicts a pediatric intensive care unit's journey from the staff nurse perspective. As outlined in the individual stories below, these best practices provide creative and well-rounded approaches to promote certification.

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Aultman Hospital Best Practice

Background

Aultman Hospital is an 808-bed, Magnet-designated facility in Canton, Ohio, whose mission is to lead the community to improve health. In addition to operating 6 centers of excellence, Aultman is a teaching hospital featuring 5 residency programs and has a nursing education program, Aultman College of Nursing and Health Sciences. For the fourth year in 2010, Aultman was named one of the 100 top hospitals in the country by Thomson Reuters. In addition, Aultman is Stark County's largest and “most preferred hospital for overall quality and image” for the 14th consecutive year, as named by the National Research Corporation.18

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Building the Foundation

The journey toward creating a culture of certification throughout the cardiac division began in 2001 with the creation of a cardiac curriculum based on 5 levels. Before the curriculum's development, cardiac staff education was offered via a traditional approach with classes offered as needed, but without formal structure and minimal support toward certification. The purpose of the curriculum was to provide structured cardiovascular and critical care education to the staff using Patricia Benner's Novice to Expert model as the framework and to encourage staff members to seek specialty certification (Table 3).19 The cardiac curriculum covers advanced knowledge—that is, beyond critical care orientation and new staff education requirements.

Table 3: Aultman Hea...
Table 3: Aultman Hea...
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Each level of the curriculum is designed to build on the previous level and introduce new content appropriate to the developmental level of the clinician. Curriculum content was identified using current cardiovascular and critical care examination blueprints, practice standards, and quality measures. The curriculum is reviewed annually for needed revisions. Free continuing education credits are provided to participants, with a total of 80 education hours available for completion of the program. The first 3 levels of the program consist of 1-hour sessions with each level providing 16 hours of education, whereas the fourth level consists of a 32-hour certification preparation course (Table 4).

Table 4: Aultman Hea...
Table 4: Aultman Hea...
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The heart of the curriculum lies in the approximately 30 clinical instructors (CIs) who take ownership of development and presentation of each class. Instructors must be master's-prepared or have specialty certification. The cardiac CIs are currently engaged in bedside practice. Instructors consist of cardiac advanced practice nurses, cardiac sonographers from the noninvasive heart laboratory, bedside nurses from the CCU, cardiovascular surgical intensive care unit staff, invasive cardiac catheter laboratory staff, and cardiac rehabilitation unit staff (Figure 1). This group meets monthly as a formal shared decision-making committee. The Cardiac Staff Education Committee (CSEC) is responsible to review curriculum content, current cardiovascular and critical care literature, and evidence-based practice standards. The committee also addresses instructor and creative teaching strategy skill development. Peer review of class content and teaching strategies is conducted on a routine basis. An annual “Instruct the Instructor” workshop is presented by the committee's chairs.

Figure 1:. Aultman H...
Figure 1:. Aultman H...
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During the past 2 years, the CSEC has worked to broaden the program's framework to include the AACN Synergy Model for Patient Care. This model is based on the fundamental tenet that patient characteristics drive nurse competencies (Table 5).20 When patient characteristics and nurse competencies are in synergy, optimal patient outcomes result.21 Instructors have incorporated relevant patient characteristics and nurse competencies from the Synergy Model into class content to stimulate critical thinking.

Table 5: AACN Synerg...
Table 5: AACN Synerg...
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The Cardiac Staff Education Program (CSEP) is designed to challenge bedside clinicians to continue to improve their practice. Throughout each class, clinicians learn new practice skills or critical thinking skills they can apply. One key strategy has been to link education at each program level to the bedside. The Linking Knowledge to Practice initiative includes clinical practice expectations for each class. These expectations reflect practice changes that can be measured in clinical practice (Table 6). Clinicians are expected to apply these practice standards in their daily practice. By linking knowledge learned in the classroom to practice, correlations between knowledge and outcomes can be identified. In addition to discussing these linking knowledge to practice expectations in the classroom, teaching strategies include “call out” slides in PowerPoint presentations and pocket cards delineating clinical expectations.

Table 6: Linking Kno...
Table 6: Linking Kno...
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Building Confidence: Creating Unit Culture “One Nurse at a Time”

The CCU is a 56-bed unit with more than 110 registered nurses (RNs), advanced practice nurses, and support staff. The staff of this 3-time Beacon Award–achieving unit provide care to medical cardiac patients who require both intensive care and step-down levels of care. Although the CSEP serves as the educational structure for the CCU, building confidence “one nurse at a time” has been the approach to create the unit's certification culture. A personal education plan is developed by the unit-based CNS and individual nurse. This plan is reviewed annually and addresses how the nurse prefers to complete the 4-level cardiac curriculum. New RN hires are oriented to the curriculum at the beginning of the orientation process.

A common barrier identified by staff nurses to becoming certified is a fear of failure. Building confidence through a variety of initiatives has been a key strategy to increasing the number of certified staff. Upon initiating the level 4 certification preparation course, staff members receive a certification packet that includes the AACN Certification Exam book and an orientation to available study resources. These resources include the CCU lending library/resource room, which has a computer for online independent learning, CD-ROM tutorials, cardiac/critical care resource manuals, and articles available for sign-out.

Formal study groups have been implemented by the unit-based CNS after completion of the level 4 certification preparation course using a case study/synergy model approach to study. Certification candidates are encouraged to partner with a certification “buddy” for study tips, test-taking advice, and support. Supportive hand-written notes from certified staff provide a nurturing and positive way to decrease fear and build confidence. The CSEC instructors share their personal and professional meaning of certification to clinical practice within the Annual Staff Education Program book provided to staff.

Celebrating and recognizing certified staff are critical elements toward creating the unit's culture. Announcing a newly certified nurse via the Nursing Board for Clinical Improvement newsletter recognizes the nurse's achievement throughout the hospital. Recognition at the unit level includes an all-unit e-mail announcement, shift huddle announcement with staff present as the certified nurse receives a certification pin, celebration fruit or vegetable tray during meal break, and the addition of the nurse's name to the certification plaque hanging on the unit's wall of fame. Certified nurses are recognized annually throughout the hospital during National Certification Week by administrative letters, media publications, and unit meals. The hospital is financially supportive of reimbursing examination fees upon successful passing of the exam.

The number of certified nurses in CCU has increased since the curriculum was first implemented. Before the CSEP, only one CCU nurse held certification. Currently, 26% of eligible staff members are certified; several others were planning to complete the curriculum and become certified by the end of the year. Engagement of new staff has increased since implementation of the individualized education plan with the majority completing the curriculum within 3 years and verbalizing commitment to obtain certification during 2011.

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Integrating the “Culture”

Creating a culture of certification should come full circle and be seen at the bedside, where excellent patient outcomes can be measured. Aultman Hospital is a 2-time recipient of the American Heart Association/American Stroke Association Triple Gold Recognition program. In 2010, the hospital received the Get With the Guidelines Gold Plus award for meeting heart failure quality measures. These awards exemplify the day-to-day commitment of the nursing staff toward excellent clinical practice. The CCU celebrated receiving the AACN Beacon Award for the third time in 2010. This unit has achieved a 0% infection rate for ventilator-acquired pneumonia and central catheters for the past 2 years. Excellence in clinical practice is also acknowledged as the CCU consistently receives high patient satisfaction scores.

Certified nurses are role models of bedside excellence and are active in efforts to implement practice change on the unit and impact patient outcomes. They have realized that certification is not an endpoint but one marker along the journey to practice excellence. Certified nurses are more likely to consistently perform curriculum “practice links” versus noncertified nurses. They are involved in unit-based, division, and hospital-level shared decision-making councils. Many have become involved as CIs within the CSEP and unit-based preceptors, and with quality improvement projects.

The CCU is currently working to take bedside practice to the next level and integrate the culture into other unit processes. In the words of AACN Past President Caryl Goodyear-Bruch, “Preparing for certification increases our knowledge, confidence, and empowerment to control our practice and impact patient outcomes.”22 Unit-based competency expectations are changing to incorporate the curriculum's practice links and nurse's level of practice. Orientation “readiness” to other roles and skills, such as charge nurse and unit preceptor, are being discussed to more clearly define and identify expected knowledge and practice outcomes. Annual evaluation goal-setting for CCU staff hired since 2009 now includes a clinical practice component based on the CSEP practice links.

The unit's goal is to exceed the 33% certification rate established for the facility by the Magnet Recognition Program and move toward a 100% certified RN staff. We are certain that we can achieve that goal by continuing to link knowledge to the bedside and building confidence through a supportive environment.

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PVAMC Best Practice

Background

Portland Veterans Administration Medical Center is a 303-bed Magnet-designated facility in Oregon whose mission is to honor American veterans by providing exceptional health care that improves their health and well-being. Housed inside PVAMC is a complex 28-bed combined medical-surgical critical care unit that promotes the organizational mission through professional certification in critical care nursing (CCRN). As veterans and the public in general place more emphasis than ever on the safety and quality of health care, they also demand expert nursing and medical care. Professional certification is one way in which the PVAMC critical care nurses show the veterans and their families, their employer, and colleagues that they possess advanced nursing knowledge, experience, and competence.23 Organizationally, certifications aid in maintaining an effective and engaged workforce, increasing retention and recruitment while enhancing professional development.24

The PVAMC critical care unit embraces the Magnet philosophy of recognizing quality patient care, nursing excellence, and innovations in professional nursing practice.25 The unit is proud of its exceptional results in quality nurse-sensitive indicators such as ventilator-acquired pneumonia, catheter-related blood- stream infections, and falls prevention.

In early spring of 2008, the critical care nursing staff expressed interest in pursuing the AACN Beacon Award for Critical Care Excellence. As the nursing leadership began looking into the award criteria, it was recognized that the unit's culture around certification was in need of improvement; only 6 (6.8%) of the 75 nurses were CCRN certified. Concurrently, the Veterans Health Administration Office of Nursing Services demonstrated its commitment to professional nursing specialty certification by launching the “Let's Get Certified Campaign” in May 2008. This campaign was designed to serve as a catalyst for innovative ideas initiated and led by VA nursing staff to develop a comprehensive program to promote, support, reward, and recognize specialty nursing certification.24 The 2008 nursing strategic plan included increasing the percentage of nurses certified in their specialty areas. Understanding the value of certification to patient and staff outcomes, the critical care nursing leadership launched its own campaign to increase the percentage of CCRNs.

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Strategies for Promoting Certification

The Inpatient and Emergency Services Division nursing director, critical care nurse manager, and CNS formed a team and identified a plan detailing the support that would be required to start a successful campaign to change the culture regarding certification. To change a culture, one must understand the existing one. The unit's nursing leadership team examined the perceptions and barriers to CCRN certification with the staff. Anecdotally, themes such as fear of test taking, not wanting to study and test alone, previous organizational years in which certification was not supported/recognized, and cost of the examination emerged. Using the PVAMC-shared governance model of inclusion and empowerment of nurses as a conceptual framework, strategies were identified to remove barriers to certification. These included setting unit goals, using interdepartmental partnerships, and initiating unit-based study groups.

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Setting Obtainable Unit Goals

Goal-setting provides a clear target for a team to aim for in addition to measuring progress and evaluating implemented strategies. Once the current CCRN rates were identified and the existing barriers to becoming certified were understood, leadership set both short- and long-term target goals for improvement. These goals were incorporated into the different phases of the Veterans Administration's Let's Get Certified Campaign. An initial goal was set for 33% of critical care staff to be CCRN-certified during phase I (May 2008–May 2009) and a long-term goal of 50% by May 2010. Figures 2 and 3 demonstrate the growth in CCRN certification during phases 1 and 2 of the campaign. Although the set targets were not met, 23% and 35%, respectively, were achieved. Nursing leadership quickly noted the effects that the unit certification efforts promoted, including team cohesiveness, collaboration, and meaningful opportunities in setting goals, and celebrating successes consistent with those outlined in the literature.26

Figure 2:. Percentag...
Figure 2:. Percentag...
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Figure 3:. Total num...
Figure 3:. Total num...
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Interdepartmental Partnerships

In July 2008, the critical care nursing leadership partnered with other departments including the library service and the education department. The library service obtained CDs, books, and other resources to develop a CCRN library for the nurses to access on the unit. The education department sponsored an in-house CCRN review course in October 2008, which featured a national speaker. Nineteen of the PVAMC critical care nurses and 5 community participants attended. Organizational support was vital in getting the initial campaign off the ground and demonstrated the commitment across the medical center to the value of certification.

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Unit-Based Study Groups

A key successful strategy for the PVAMC critical care unit was implementation of a unit-based study group. In September 2008, an 8-week didactic study session was developed and coordinated by the CNS. The weekly sessions were structured using the AACN Blueprint27 for the examination and used the CNS and certified nurses as educators. Initially, educators were selected on the basis of their clinical expertise. The CNS coached each staff educator through the development of the 2-hour class. The first hour focused on didactic content with a Microsoft PowerPoint presentation and handouts, and the second hour consisted of interactive activities with practice examination questions, game show-style activities, paper-and-pencil games (eg, crosswords, word searches, definition matches), or any combination of these, which emphasized the principles of adult learning theory. These strategies kept the staff engaged. Active participation results in longer-term recall synthesis and problem solving than verbal didactic instruction exclusively.28

Each week, the study materials and staff presentations were made available in the CCRN library and on the unit. In addition to the didactic content, information on how to sign up for the examination and details of the Let's Get Certified Campaign were reviewed. The campaign provided not only a discount on the examination but also a free 1-year membership to AACN.

The unit-based study sessions highlighted the unit's dedication to and support of the campaign. These sessions reduced the previously identified barrier of “doing it alone” and generated a team approach to seeking certification. One staff participant described these sessions: “Studying together increased the morale and rejuvenated each staff member's nursing soul.” In addition, staff members began to recognize their peers for their expertise as educators, leaders, and mentors. The staff educators were able to document their professional development activities in their annual professional appraisals. The PVAMC critical care unit has continued the staff-led study groups in both March 2009 and February 2010 and offers nurses the time and tuition to attend a review course offered by the Greater Portland Chapter–AACN as well.

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Keeping the Momentum and Celebrating Successes

The importance of recognizing certification is well documented in the literature.26 The PVAMC critical care unit recognizes each certification with a congratulatory e-mail announcement sent to all unit staff and a successful achievement certificate from the nursing leadership team. A CCRN pin is presented at staff meetings or informal unit gatherings. The staff's CCRN certificates are proudly displayed on the staff achievement wall. This wall celebrates certifications, in addition to medical center awards and the staff's organizational anniversaries. The unit also recognizes the value of certification through an annual cake celebration March 19 to mark Certified Nurses Day (Figure 4).

Figure 4:. Portland ...
Figure 4:. Portland ...
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Organizational recognition of certification is critical to supporting a culture of certification. The primary incentive to become certified rests with an individual nurse; financial incentives enhance support of the overall organizational initiative.26 At PVAMC, a nurse is eligible for a certification award on initial certification. This is a monetary award that is honored for up to 2 initial certifications.

The PVAMC critical care unit's great strides in promoting a culture of certification have been recognized by both the national office and local chapters of AACN. The August 2009 publication of AACN Bold Voices29 acknowledged the successes of the Let's Get Certified campaign with a specific notation to growth in CCRNs in the PVAMC critical care unit. Locally, the Greater Portland Chapter—AACN recognized the unit at the 36th Annual Fall Symposium (2009) with a poster (Figure 5) celebrating CCRN growth. Within the Veterans Health Administration, PVAMC was recognized in the initial phase of the Let's Get Certified campaign with the first place Gold Level Achievement Award. This top-level award was given to medical centers that reach the milestone of 25% or more of all nurses certified and 25% or more of direct care nurses being certified through creative and innovative approaches that support the program goal.24 The critical care unit's participation in this campaign helped propel PVAMC to receipt of this prestigious award.

Figure 5:. Greater P...
Figure 5:. Greater P...
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Outcomes

As documented in the literature, certification provides recognition of the nurse's knowledge and expertise in a specialty area. Certification has been linked to empowerment. The need to create a work environment that empowers nurses is an important issue facing health care and the nursing profession.30 As the numbers of CCRNs have grown, so have the number of informal CCRN nurse leaders. With development of the CCRN staff–led study sessions, a pool of experienced staff educators and speakers has emerged. Initially, the CNS served as the educator for many of these sessions. Currently, these sessions are led primarily by the CCRN-certified staff who are mentored and coached by the CNS. In turn, the certified staff members encourage the noncertified staff. These role models assist noncertified staff in preparing for testing. They share study materials and help nurses sign up for the examination.

The CCRN staff members assume many unit-level leadership roles including unit-based committee chairs and address nursing issues on the unit. Such empowerment and recognition of nurses results in nurse retention. Certification provides one avenue for leadership to not only develop but also maintain its highly trained workforce.24,28

The experience of the PVAMC critical care unit has been one of a “contagious culture.” Initially, as the first few passed the CCRN examination, others quickly gained confidence by watching the success of their peers. As a healthy and competitive environment began to develop, some senior staff members were challenged by newer staff successfully obtaining their certification; they began taking the examination as well.

As described in the literature, once a successful certification program has been implemented, additional specialty certifications will follow.26 As CCRN certification became part of the unit culture, subspecialty certification examinations emerged, such as Cardiac Medicine Certification, Cardiac Surgery Certification, and neuroscience certification (CNRN) to name a few. Currently, 11 additional specialty certifications have been obtained by the critical care staff. And as stated by one nurse “because our unit is a large medical-surgical unit with a broad range of services, these certifications create a well-rounded and highly educated staff.”

The certification experience at the PVAMC critical care unit has been extremely positive and contributes to a professional and healthy working environment. The CCRNs were asked to reflect on their own certification experiences and the significance to their daily practice. One highly experienced nurse new to the unit stated, “Every time you prepare for an exam, you learn something that adds to your practice and benefits your patients' outcomes.” Another nurse enthusiastically responded about the examination preparation process, “It was a good review, revived a sense of collegiality, and improved my confidence in caring for more complex patients.” A third nurse responded about the continuing education required in maintaining certification, stating, “My CCRN continues to provide me with a source of inspiration to continue professional education in a variety of ways.” Another explained, “CCRN is about promoting your profession and having credibility among your multidisciplinary health care team members.” These responses summarize the experience and growth of the PVAMC critical care unit in its journey to create a culture of certification.

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The Children's Hospital of Philadelphia's Pediatric Intensive Care Unit Best Practices

The Children's Hospital of Philadelphia (CHOP), the first pediatric hospital in the nation, is a 431-bed Magnet-designated organization. In 2009, CHOP was rated the No. 1 pediatric hospital by Parents magazine.31 Children's Hospital of Philadelphia was featured in US News & World Report's America's Best Children's Hospitals issue and has consistently ranked among the top-10 US children's hospitals.32 The 45-bed pediatric intensive care unit (PICU) provides advanced diagnostic and therapeutic multidisciplinary care to critically ill children and their families. Our more than 200 PICU nurses are committed to patient safety and family-centered care.

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Specialty Certification Goal

Specialty certification is valued in the PICU for several reasons, including increasing evidence suggesting that certification is a factor in improved patient outcomes.4,33,34 Specialty certification promotes participation in continuing education and professional development. The literature also suggests links among certified nurses' job satisfaction, empowerment, and improved staff retention.24,30,35

The Pennsylvania Trauma System Foundation sets accreditation standards for hospitals caring for trauma patients. One of the accreditation standards is for the PICU to have 50% of the nurses who have worked for 3 years or longer become certified. Historically, there were always several nurses in the PICU who were CCRN certified. Efforts to significantly increase the percentage of staff who achieved pediatric CCRN status began in earnest in early 2000. Following a needs assessment, it was determined that development of resource materials and a formal review course were needed. Pediatric intensive care unit CCRNs were mentored as lecturers by the unit-based CNS and a 2-day course was implemented in the spring 2001. Over the past decade, the appreciation of the value of specialty certification has increased throughout the unit.

In 2007, 25% of eligible PICU nurses were pediatric CCRN certified. In 2009, realizing the importance of continuing to increase the number of certified nurses, a small group of nurses revisited this opportunity. This group, which included the PICU's nurse manager, CNS, chair for the Supporting Practice and Management shared governance council, and a unit-based education leadership nurse, partnered to promote certification and retention efforts on the unit. Several revisions to our certification strategies were implemented.

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Identifying and Overcoming Challenges to Conquering the Pediatric CCRN Examination

On the basis of a staff survey and individual staff discussions, several challenges to conquering the pediatric CCRN examination were identified. These challenges include test anxiety, limited availability of pediatric CCRN practice questions, lack of a pediatric CCRN self-assessment examination, availability of funds for the examination, individual motivation, and uncertainty of the benefits of certification. In addition, several staff members indicated lack of knowledge and expertise in caring for certain patient populations, as the PICU and cardiac intensive care specialty units care for different complex patient populations. Multiple pediatric growth and developmental considerations can be challenging on the examination, such as unrepaired cardiac defects and differing common causes and presentations of respiratory distress from infants to teenagers. To overcome these challenges, the nursing leadership team partnered together to promote, support, and recognize specialty certification.

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Reaching Out to Eligible RNs

Certification promotion strategies begin as staff approach 2 years of PICU experience (see Figure 6). We individually reach out to all eligible PICU RNs. Staff receive a personalized e-mail stating: “Congratulations! You are eligible for Pediatric CCRN! Join us for the certification journey.” Personalized invitations to attend the Pediatric CCRN Review Course are sent to each eligible nurse. The leadership team consistently encourages staff to pursue certification during middle and end-of-year evaluations. CCRN materials are distributed to staff, and flyers advertising the course as well as the benefits of certification are posted. Current research on the benefits of certification and the AACN statements on certification are e-mailed to staff. The hospital sponsors an annual Professional Development Fair advertising available specialty certifications. During this time, the PICU provides information about becoming a pediatric CCRN.

Figure 6:. Certifica...
Figure 6:. Certifica...
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Two-Day Pediatric CCRN Review Course

The PICU offers a 2-day Pediatric CCRN Review Course 3 times a year. The course is modeled after the test blueprint. Recognizing that despite the best of intentions, many people fail to follow through and take the examination following a review course, PICU nurses must now register for the CCRN examination before attending the review course. Once registered, attendees receive paid conference days to attend. Attendees receive 14 Pennsylvania State Nursing Association–approved continuing education credits, including trauma hours based on the percentage of trauma topics covered during the course.

The course includes practice questions, study preparation hints, and test-taking tips. All presenters are pediatric CCRNs and participate in the development of practice test questions. In partnership with nursing staff from the cardiac intensive care unit, the cardiac portion of the course is taught by experienced cardiac intensive care unit CCRNs. Practice test questions are incorporated throughout all presentations. The review course also includes 2 separate half-hour presentations based solely on practice questions. Staff comments on the course evaluations have revealed that the practice questions are helpful and that more questions were desired to help better prepare for the examination.

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Unit-Based Resources

Growing our certification resources is a priority for the leadership team. Examination preparation resources such as review materials, practice questions, books, flash cards, and CDs are stored in the PICU library. Certification handbooks and Renewal by Synergy CERPs pamphlets are available on the unit. A Pediatric CCRN Guardian Angel card is distributed to staff with encouraging words, while staff study and prepare for the examination. Most importantly, pediatric CCRN peers are extremely influential. Peer support is identified in the literature as a motivator for nurses to pursue certification.33 Peers support and encourage others along the certification journey. CCRN peers help to take the mystery and fear out of taking the examination by sharing how they prepared for the examination and what the examination was like for them. In the spirit of healthy competition, we post the number of certified nurses in each of the 7 nursing teams on the unit. This allows staff to see how their team compares with other teams on the unit. As more nurses become certified, more nurses want to be certified.

Unfortunately, not everyone passes the pediatric CCRN examination on the first try. With peer support, there is more transparency and willingness of staff to talk about not passing the examination. A network exists where peers share examination topics and strategies to pass the examination on the second attempt.

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Congratulations! Next Steps for Recognition

Recognition is an important factor in certification promotion.3,16,36 Achieving certification status is recognized both within the PICU and hospital-wide. The hospital offers a certification bonus for all newly certified RNs. Hospital-wide nursing-shared governance councils partner to sponsor a certification breakfast during the annual professional development fair. Certified nurses from different practice areas are recognized during these events.

New CCRNs are announced at unit staff meetings and receive recognition “Bravo Cards.” Congratulatory e-mails notify all PICU staff that we have new CCRNs, and the names of newly certified nurses are sent to the tristate Nursing Spectrum magazine. The PICU's recognition committee distributes gift bags and updates a bulletin board with names of certified nurses. Achieving CCRN status is reflected in nurses' individual annual evaluations under the core competency categories of “delivering excellence” and “commits to service.” Once nurses are certified, we give them preference to function in charge, clinical resource, or intravenous placement nursing roles.

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Outcomes

Our unit experienced a surge of 25 newly certified pediatric CCRNs in 2009. We attribute this huge success to 3 critical factors: peers present at review courses and provide support for future CCRNs, increased recognition and celebration of achieving pediatric CCRN status, and CCRN examination registration is required before attending the review course to ensure that nurses are fully committed to the certification journey. Currently, we are tracking the percent increase in pediatric CCRNs and the certification examination pass rate after RNs attend our review course. In April 2010, the PICU had 49 CCRNs (35% certified staff) of the 139 eligible RNs. As of July 2010, there are 52 CCRNs of the 146 eligible RNs (the PICU certification status remains at 35%). Eight PICU nurses are currently preparing for the examination; we anticipate an increase in PICU CCRNs by the fall of 2010. The examination pass rate in 2009 was 83% (25 of 30 staff passed the examination).

To determine which examination preparation resources are the most helpful for staff as a whole, we are in the process of resurveying the staff. We will use these results to determine strategies to effectively revise our certification promotion and examination preparation resources. Our specialty certification goal is to increase the number of eligible PICU nurses who successfully achieve pediatric CCRN certification by 15% by June 2011.

Staff members in the PICU at CHOP continually strive to provide excellent clinical and family-centered care to all patients and families. Specialty certification demonstrates both a commitment to the provision of safe, exceptional patient care and the continuous learning and professional development of staff. Various stages of the certification journey are shared among nurses throughout the PICU, and both formal and informal support systems have evolved. The achievement of certification is contagious. As more nurses become certified, we will further develop support systems for certification achievement and renewal and anticipate our certification culture to thrive.

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Summary

NTI's 2010 Creating a Culture of Certification: Best Practices Roundtable provided a forum for nurses to share and discuss successful experiences and strategies for encouraging nurses to take the certification journey. Three diverse practice environments (a CCU, a medical-surgical critical care unit, and a pediatric intensive care unit) share common certification themes including the 5 themes identified by AACN's best practice units: commitment to excellence, supportive and encouraging environment, setting a goal/goal-directed evaluations, available resources, and celebration/rewarding excellence. All 3 of the hospitals highlighted in this article embraced these themes using different but successful approaches.

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Acknowledgments

The authors thank Leslee Dennis, Aultman Corporate Communications; Cheryl Hecht, RN, MSN; Patricia Hubbs, RN, MSN, CCRN; Karen Marzlin, RN, MSN, CCNS, CCRN-CMC; Floss J. Mambourg, MS, MPA, RN, NEA-BC; Jeannette Richardson, RN, MS, CCRN, CNRN, CNS-BC; Kathryn Roberts, RN, MSN, CNS, CCRN; and Cynthia Webner, RN, MSN, CCRN, CCRN–CMC, for their assistance in the review of this manuscript.

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best practice; certification; certified practice; value of certification

© 2011 American Association of Critical–Care Nurses

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