The achievement of an RN license signifies attainment of the basic knowledge needed to practice nursing at an entry level of practice. Health care has become increasingly complex with constant changes in treatment and technology. When nurses seek knowledge in a nursing specialty, they are demonstrating a commitment toward increased knowledge in that specialty. Certification is a process by which an agency validates, on the basis of standards, a nurse's knowledge for practice in a clinical area of nursing.1 Ultimately, the nurse, patient and family, and employer benefit from the nurse's knowledge of their specialty.2
Certification is defined by the American Board of Nursing Specialties as the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes.3 As of 2000, more than 410 000 nurses had been certified in the United States and Canada, representing 67 certifying organizations offering 95 different credentials across 134 specialty organizations.4 The American Association of Critical-Care Nurses (AACN) Certification Corporation reports that there are more than 60 000 nurses who hold the CCRN, PCCN, CMC, CSC, ACNPC, CCNS, or CNML credential.5
According to the American Nurses Credentialing Center document on the benefits of certification, the value of certification extends beyond the individual nurse to impact autonomy of nurses. In addition, there is a positive impact on the work environment.2 Hospitals pursuing Beacon Award for Excellence, Magnet designation, or the Malcolm Baldrige National Quality Award recognize that certification is a key component of excellence.2 The AACN Certification Corporation delineates multiple benefits of certification for patients, families, employers, and nurses.5
Certification is not a one-time achievement. To renew certification, nurses are required to work a certain number of hours in their specialty and either retake the certification examination or complete a predetermined number of continuing education hours in their specialty.
Despite the benefits of certification described in the literature, some nurses may not seek certification. There are many reasons why nurses fail to seek certification. A survey conducted by the American Board of Nursing Specialties revealed that the major barriers to certification were cost of the examination, lack of institutional support, and lack of rewards for becoming certified.3
When 1 assistant nurse manager of an intensive care unit recruited a group of nurses who were interested in becoming CCRN certified, she found the fear of the examination to be the major barrier preventing nurses from testing. Moreover, she found the cost of the examination to be the second largest barrier to nurses who were interested in taking the CCRN examination.6
Support for Certification
In 2004, AACN included questions in its national critical care survey that evaluated organizational and unit culture for certification.7 Study findings included that financial support for certification was most frequently offered for examination fees. Nurses from 50% of the units who responded to the survey reported the requirement of passing the certification examination before receiving reimbursement for examination fees. The authors also reported that 43% of facilities reimbursed employees for certification renewal. Data from the survey also revealed that smaller critical care units were more likely than larger critical care units to pay for certification review courses. Most of the facilities that responded to the survey recognized their certified nurses publically.7
Impact of AACN Certification Corporation and White Paper
The AACN Certification Corporation was established in 1975.7 The primary purpose of the AACN Certification Corporation is to promote and enhance consumer health and safety by establishing and maintaining high standards of professional practice excellence through acute and critical care nurse certification. Currently, AACN offers the following certifications for acute and critical care nurses: CCRN, CCNS, PCCN, ACNPC, CMC, CSC, and CNML in collaboration with the American Organization of Nurse Executives (AONE).
The AACN white paper Safeguarding the Patient and the Profession published in December 2002 was a bold step in support of certification.8 AACN possessed the vision to recognize that critical care nurses needed a way to validate specialized knowledge and skills. The white paper put forth a call to action for all who could influence and will benefit from certified nurses' contribution to patient care. As described in the white paper, patients, employers, and nurses benefit from holding a specialty certification. Certification signifies to patients that their nurse has met rigorous standards of that specialty.8
AACN Chapter Initiative
The Heart of the Piedmont chapter is composed primarily of nurses who are employed by High Point Regional Health System (HPRHS). Heart of the Piedmont has a history of strong administrative support. Chapter meetings are held on the campus of HPRHS, and HPRHS administration encourages and supports nursing involvement in professional organizations.
In 2000, the Heart of the Piedmont chapter was experiencing low membership and was almost disbanded. Dwindling chapter interest was a wake-up call for chapter leaders. Behind the scenes, the chapter founder began to strategize on ways to reinvigorate the chapter. It was determined that a chapter strategic-planning meeting was urgently needed to organize ways to reinvigorate the chapter. A group of past chapter leaders, current leaders, and staff nurses was invited to attend a chapter strategic-planning meeting. From that meeting, the message was loud and clear that chapter members, leaders, and staff nurses did not want to disband the chapter.
Multiple meetings were subsequently held after the initial 4-hour meeting. During one of the meetings, a Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis was performed. One of the themes that recurred during the SWOT analysis was the limited number of certified nurses in the chapter. After the strategic-planning meeting, a needs assessment was sent to all critical care units. The needs assessment results revealed a high interest in certification. Chapter leaders decided to take this a step further and sent a survey to all critical care nurses in the organization to determine interest in obtaining certification and taking certification review classes. Ninety nurses returned the survey, and 100% indicated interest in taking the CCRN examination.
Strategies for Certification
Information sessions were held with a large number of individuals who were interested in obtaining CCRN certification. Initial meetings consisted of CCRN examination information, including benefits, cost, study materials, and the examination blueprint. Information-session attendees indicated an interest in attending study groups. Next, current CCRNs were asked to volunteer to be a certification coach and study group leader. The CCRN coaches were encouraged to attend education sessions on how to be a successful coach. Coaches were given the book Everyone Is a Coach: Five Business Secrets for High Performance Coaching by Blanchard and Shula,9 coach hats, and whistles in an effort to motivate the study groups. The CCRN study materials were distributed to each coach for each study group.
On the basis of availability, optimal meeting days and times for the study groups were determined. Next, interested individuals were invited to sign up for one of the study groups. Five diverse groups consisting of 7 to 8 interested critical care nurses were formed. Some groups met at the homes of potential examination candidates, and others chose public meeting places. Most of the individuals participated in the weekly group meetings throughout a 3-month period of time. However, despite informational and coach sessions, few nurses decided to take the certification examination. Chapter leadership began to look at barriers to taking the certification examination.
A survey evaluating interest in and barriers to certification was distributed to individuals who initially indicated an interest in taking the CCRN certification examination. The chief identified barriers were cost and fear of failure of the examination. These barriers were consistent with those reported in the literature.8 Heart of the Piedmont chapter leaders approached affiliated senior nursing leadership regarding a proposal for prepayment of the examination. Senior leaders at HPRHS agreed to prepay examination fees for individuals who would agree to take the certification examination. Individuals who either were in the process of preparing for the examination or had indicated interest were notified of examination prepayment. Despite prepayment, only a few nurses actually scheduled a date for the examination.
Chapter leaders struggled to understand which additional barriers were keeping individuals from testing. An informal survey was distributed. This time, the primary barriers identified were fear of testing and lack of preparation for the test.
Heart of the Piedmont chapter leaders again strategized on the next steps. Despite a lack of chapter funds, chapter leaders envisioned contracting with a nationally known certification speaker. After considering options and cost, a speaker was selected. However, the chapter did not have the financial capability to hire a speaker. In response, chapter leadership approached administration at HPRHS for financial assistance with obtaining a speaker. Financial assistance and support were obtained, and a date was chosen for a CCRN examination review course.
Attendance at the 2-day review was excellent, with 91 critical care nurses present. Surprising to chapter leaders, the evaluations of the 2-day review were not entirely positive. Almost 25% of the participants expressed dissatisfaction with the speaker. Some of the comments included remarks such as “Speaker is over my head” and “I could not follow the speaker's presentation.” Chapter leadership did not anticipate the waning certification interest after the 2-day review course. After the review, some of the participants said the course made them feel inadequate. Again, chapter leaders began to discuss barriers and the fact that in their zest to encourage certification, perhaps it was unintentionally implied that certification was easy to obtain.
No Turning Back
Despite the numerous disappointments experienced, Heart of the Piedmont chapter of AACN remained committed to certification. Although we had lost at least half of the interested nurses, there were 40 other nurses who remained interested. Our chapter continued to support interested individuals with study aids, encouragement, and arranging prepayment of the examination. As months passed, fewer individuals were considering testing. In response, Heart of the Piedmont printed Commitment to Test cards and distributed them to nurses who had previously been interested in testing. Interested nurses were asked to sign the card and commit to set a certification examination date. Twenty Commitment to Test cards were returned to chapter leadership.
Chapter Meetings and Certification
Sample questions from AACN's practice CCRN examination were included in every chapter meeting. A certification “Jeopardy!” session was held several times during the year on the weekend. Chapter leaders continued to keep certification at the forefront of every meeting. In addition, some special meetings were planned. Roberta Kaplow, coeditor of Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care and Critical Care Nursing: Synergy for Optimal Outcomes,10 was invited to present information on the Synergy Model to Heart of the Piedmont chapter members. The chapter reached out and invited area critical care nurses who were not members of AACN to attend the Synergy Model presentation. This presentation was repeated, so that 2 presentations on the Synergy Model were held during a 3-year period.
Heart of the Piedmont chapter hosted the Region 5 (North and South Carolina chapters of AACN) meeting in 2007. In an effort to extend Heart of the Piedmont's vision, certification was given a spotlight during the day-long regional meeting. Sonya Hardin, coeditor of Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care and Critical Care Nursing: Synergy for Optimal Outcomes,10 was a featured speaker at the Region 5 meeting; she presented information on the Synergy Model.
Heart of the Piedmont leaders discussed continuing education reviews for the CCRN examination. The first attempt at education for the CCRN examination had not been entirely successful. During chapter board meetings, there were discussions regarding education preparation for the examination. Ultimately, it was decided that critical care educators from our chapter would be invited to present a 2-day review course.
A successful 2-day review course sponsored by the chapter was held for 2 consecutive years. During our second year, there were complaints from one of the critical care managers regarding the number of staff members who were attending the review course and the impact on the unit. In addition, some nurses were denied time off to attend the review. The critical care manager allowed chapter members and those who had signed intent-to-test cards first preference to attend the review. Ultimately, the chapter decided to modify the education plan to accommodate all interested nurses.
Chapter nurses were surveyed regarding the best times for review courses. The majority of nurses preferred late afternoon, and sessions lasted 2 to 3 hours each. Certification classes began to be offered annually for 10 weeks and were structured on the basis of content from the Core Curriculum.
Certification was an ongoing yearly effort for the chapter. Over the first few years of our certification efforts, critical care nurses began to test and have success. Recognition of a new CCRN served as encouragement to others who were thinking of testing. Sixteen nurses sat for the CCRN examination in 2003; 13 (81%) were successful. Twenty percent of the newly certified CCRNs in North Carolina in 2003 were members of the Heart of the Piedmont chapter. Despite success, chapter leadership continued to evaluate strategies to promote certification. Heart of the Piedmont leadership continued to investigate barriers to certification. On investigation, another barrier surfaced. This barrier was related to the travel distance to the testing site. The AACN corporation was approached regarding the feasibility of establishing a local test site for interested nurses. The corporation agreed that the test-site distance was an issue for the chapter and agreed that a paper-and-pencil test could be held locally.
Chapter leaders assisted with the coordination of the site and collaborated with the local hospital to arrange for payment of the examination. Nurses who had previously expressed interest in the examination were notified of the upcoming local test. Twenty-two critical care nurses participated in testing. Nurses said it was easier to commit to test when they were testing in familiar surroundings. On the testing day, chapter leadership provided refreshments and posted inspirational messages in the lobby outside the testing site.
Chapter leaders decided to celebrate all of the chapter's certified nurses on a yearly basis. Certification celebrations began in 2002. Heart of the Piedmont's first celebration was a luncheon. Attendance at the first certification celebration was excellent, because almost 95% of the chapter's certified nurses attended the event. The following year, a special evening celebration was held with Connie Barden, then president-elect of AACN, as the special guest speaker. Nurse leaders from the chapter's affiliating hospital were invited and attended the event. During each subsequent year, a special dinner has been held to recognize each CCRN-, PCCN-, CMC-, and CSC-certified nurse. In addition, small gifts are given to each certified nurse as a token of recognition and appreciation for their dedication to excellence.
The Heart of the Piedmont board of directors continually explored other methods to recognize certified acute and critical care nurses. The chapter board decided that all certified nurses should be recognized on their respective unit. Financially, the board committed to purchasing 4 certification plaques to be placed on each unit at HPRHS where there were certified nurses. The goal of the plaques was 2-fold: (1) to celebrate the nurses' accomplishment and (2) to show patients and their families the dedication and commitment of the nurses who were caring for them.
A plaque ceremony was held before the placement of plaques on the acute and critical care units at HPRHS. The room where the ceremony was held was decorated with roses, white tablecloths, and silver utensils. Certified nurses, chapter leaders, and HPRHS nursing leaders were in attendance. After a brief dedication speech, the attendees were invited to unveil the plaques that were placed on each critical care unit. Subsequently, an article and the pictures of the event were submitted to and published by the hospital newspaper.
As nurses became certified, their names were placed on the certification plaque in their unit. Chapter leaders decided that although plaques were meaningful, there was often a delay in engraving nameplates once a nurse became certified. Chapter leaders decided to celebrate a nurse's certification success immediately. Chapter leadership purchased certification pins for nurses as they became certified. Nurses were encouraged to inform the chapter once they passed the certification examination. Moreover, nurses were encouraged to ask the chapter for certification assistance if needed. Once the chapter was informed of a newly certified acute or critical care nurse, a surprise pinning was planned. Chapter members coordinated with the nurse managers of the newly certified nurses to determine when they would be working. Toward the beginning of the nurse's shift, the staff and physicians gather around the nurses while they are pinned. Pictures of the nurse with coworkers and physicians are taken. Subsequently, pictures and information are sent to the hospital newspaper.
In 2001, chapter leaders asked HPRHS for the CCRN and other certifications to be added to the hospital badge. Three years later, certifications were added to badges.
Chapter Meaningful Recognition
In May 2007, Heart of the Piedmont chapter received the AACN Chapter Value of Certification Award. Nine chapter members attended the National Teaching Institute to receive the award. Members were proud to receive the award and even prouder of the outcomes of the chapter's certification efforts.
Continuing With the Vision
Heart of the Piedmont chapter continues to have success with its certification efforts. Celebrations and certification efforts continue to occur. Acute and critical care nurses in our chapter continue to become certified. One outcome of our efforts was not anticipated' chapter efforts impacted certification enthusiasm for other specialties at our facility. In 2005, all nurses seeking to certify in any specialty were provided with upfront prepayment of their specialty examination. In addition, review classes and on-site testing at HPRHS began for all specialties. The number of certified nurses began to increase throughout the organization.
The relationship with HPRHS administrators is one of true collaboration. Chapter leaders have met with HPRHS administration on multiple occasions to request assistance and have always received a positive response. Administration encourages nursing involvement in our local AACN chapter and has wholeheartedly supported all certification efforts.
In addition to our efforts to encourage certification, as a chapter, we have remembered the true meaning of certification. It is about excellence and being equipped to give the best possible care to our patients. One nurse who was unsuccessful on his first attempt at passing the certification examination summed it up quite well. As I was encouraging him to go forward and continue with his efforts, he informed me that he was not upset about not passing his examination. As he so aptly stated, “It is not about the test. It is about the knowledge that I have obtained and the journey I have undertaken. I know the care I give my patients has improved because of my increased knowledge.” He continued with his certification efforts and several months later became a CCRN.
Chapters are in a unique position to assist nurses in becoming certified in their specialty. Despite anticipated disappointments, chapters can prevail, thereby contributing to optimal patient outcomes.