Certification is defined in the nursing literature in several ways; no one consistent definition of certification exists. The American Board of Nursing Specialties (ABNS) defines it as “the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes.”1 The American Nurses Association explains certification as “the documented validation of specific qualifications demonstrated by the individual registered nurse in the provision of professional nursing care in a defined area of practice.”2(p262)
Specialty organizations also provide their definition of certification. For example, American Association of Critical-Care Nurses (AACN) defines certification as “a process by which a nongovernmental agency validates, based on predetermined standards, an individual nurse's knowledge for practice in a defined functional or clinical area of nursing.”3 The National Certification Board: Perioperative Nursing, Inc, defines certification as “the documented validation of professional achievement of identified standards of practice by an individual registered nurse providing care for patients before, during, and after surgery.”4(p1)
As there is no universal agreement on a definition of certification and more than 50 nursing certification programs with different standards exist, the value of certification is difficult to quantify; specialty certification programs' value to stakeholders will vary with the respective standards.5
Overview of The Value of Certification
Health care delivery has become increasingly challenging5 as patients with complex multisystem problems are seeking care. Technological advances abound and add to the barriers of delivering quality nursing care. As a result, health care facilities and nursing leaders seek to employ competent nurses who contribute to optimal patient outcomes.6 Certification validates advanced knowledge and competence in a specialty.7–10 As described in the white paper Safeguarding the Patient and the Profession: The Value of Critical Care Nurse Certification published by AACN, RN licensure validates entry-level competence of basic knowledge and skill to perform job responsibilities. The knowledge and experience required to successfully fulfill certification requirements exceed these RN entry-level competencies.8
Certification programs are intended for consumer protection. Certification protects the public by allowing consumers of health care to easily identify competent people.10 However, benefits for stakeholders other than patients and families are described in the literature. This article describes the value of specialty certification from the perspective of the patient and family, the nurse, and the employer.
Value to the Patient and Family
One of the most compelling reasons to become certified is to improve patient care. Consumers are increasingly vigilant about the health care system. Certification provides patients and families with validation that the nurses caring for them have demonstrated experience and knowledge that exceeds that which is assessed in entry-level licensure examinations.8
Certified Nurses Make Decisions With More Confidence
Nurses who have had their knowledge validated through a certification examination make decisions with greater confidence.7,11,12 In a study conducted by AACN, participating critical care nurses reported that being certified had a positive effect on the delivery of patient care.8 This confidence may play a role in helping nurses recognize patients' symptoms and intervene promptly and correctly.8 An anecdotal case report by a certified nurse revealed higher levels of confidence that resulted in an improved patient outcome.13 It has also been reported that 97% of nurses agreed that certification resulted in enhanced personal confidence in clinical abilities.11
“Failure to rescue occurs when a patient's condition undergoes a rapid decline that could have been avoided or mediated had a nurse intervened early and appropriately.”8(p159) Although “failure to rescue” a patient in trouble cannot always be avoided, it is felt that experienced and knowledgeable nurses will help optimize patient outcomes if they can recognize patients who are actually or potentially facing a critical event.8 Certified nurses making patient care decisions with greater self-assurance can translate into a decrease in medication errors and failure to rescue and an increase in the ability to recognize and attend to patient and family needs.8
The Plastic Surgical Nursing Certification Board conducted a study of certified nurses in collaboration with the Nurse Credentialing Research Coalition. These certified nurses reported that they endure fewer patient care adverse events and errors. They also felt that they were better able to recognize a patient experiencing complications and begin implementing interventions earlier as a result of being certified.14 These findings were corroborated in 2001 by Cary,7 who reported that certified nurses felt more competent in their skills, accountability, and confidence.
Certification has been linked to patient safety. Inverse relationships between the number of certified nurses on a unit and the incidence of falls and skin breakdown have been reported.15,16 That is, units with higher numbers of certified nurses reported lower frequency of falls or pressure ulcer development.
Clinical knowledge and competence have been identified as essential to mitigate risk of harm.17 Certified nurses have demonstrated commitment to continual learning. This attribute is desired in nurses caring for patients with complex multisystem problems and can be critical to ensuring optimal outcomes. Data from studies suggest that a large percentage of patient care incidents are attributed to a lack of training and education or related to knowledge, skill, and competence.17,18 It has been suggested that certification may decrease the risk of medication errors, inadequate documentation, and failure to attend to patient and family needs.6,8
In several studies, certified nurses demonstrated higher levels of knowledge and skills in their specialty. These skills included performance of inhaler use, simulation testing of mass casualty triage, accurate staging of pressure ulcers, participation on code blue teams, and higher than national benchmark rankings on 6 code-related indicators.19–22
Despite the positive results noted earlier, there are conflicting data in the literature. Significant relationships between certification and patient outcomes are not consistent. A correlation but no significant difference was found between the number of certified nurses in the operating room and a decrease in either operating room complications or mortality.23
Data from other studies suggest no relationship between certification and numbers of medication errors, skin breakdown, central venous catheter infections, or falls.16,24,25 Coleman and coworkers26 of the Oncology Nursing Certification Corporation Research Committee performed an ex post facto study to evaluate whether nurses certified in oncology obtained better patient outcomes than noncertified oncology nurses. Although methodological flaws were identified by the researcher, little support of their hypothesis was found. No strong evidence existed that certified nurses obtained better outcomes than their noncertified colleagues.
Certification has also been linked to patient satisfaction, from both patients' reports and nurses' perceptions.27–30 These higher patient satisfaction ratings may be attributed to reports of a decreased incidence of patient care errors and complications and better patient outcomes.31
Nurses' Perceptions of Value to Patients and Families
Schmalenberg and Kramer32 surveyed 2990 nurses who worked in one of a variety of units of Magnet-designated hospitals. The Nurse-Assessed Quality of Care tool was used to assess the participants' perception of “usual quality of care provided to patients” in their units. Certified nurses in this study reported higher mean scores than noncertified nurses.
Studies have been conducted on nurses' perceptions of the value of certification, but the findings are inconsistent. The ABNS conducted a perceived value of nursing certification study. One of the 20 organizations that participated in this study was the Board of Certification for Emergency Nursing. Both nurses who were certified and those who were not certified agreed that certification indicated to patients that the nurse was competent and qualified.33
Conversely, studies of nurses' perceptions of CNOR certification revealed that specialty certification did not demonstrate competence or guarantee competency to health care consumers.8,15 Similarly, in a study of perceived value of certification of perioperative nurses, only 45% of noncertified nurses and 5% of certified nurses agreed that certification increased consumer confidence.34
Methodological flaws (eg, sample size and study design) have been identified as limitations of select studies and could have possibly impacted the findings. Furthermore, studies that evaluate nurses' perceptions provide a snapshot view of the opinions of the participants. These opinions are likely to differ depending on the presence or absence of factors impacting the decision at that time. Opinions do not necessarily reflect what actually exists.
Adherence to Evidence-Based Guidelines
It has been suggested that patients who receive care based on evidence-based guidelines have better outcomes.35,36 Coleman and colleagues37 compared nurses certified in oncology with those who were not certified in oncology. They found that nurses who were certified were more likely to adhere to evidence-based guidelines of the National Comprehensive Cancer Network. The certified nurses also scored higher on knowledge and attitude surveys addressing pain and chemotherapy-induced nausea and vomiting. Similarly, Twibell and colleagues38 noted that certified nurses were more likely to favor family presence during resuscitation.
Value to Employers
Authors of several studies and articles have articulated the value of certification to employers.7,8,12,28,31,40 An association has been identified between certification and turnover, vacancy, staffing, nurse retention, job satisfaction, higher nurse performance, and patient satisfaction.28 The link is not consistent, however, for each of these outcomes.
In an acute care medical unit of a 750-bed academic health care facility, a 60% increase in certified nurses in 1 year was associated with a decline in the rate of nurse turnover (from 16.7% to 8.1%), a logical decrease in vacancy rate (from 11.7% to 4.73%), and an increase in patient satisfaction scores (from 88.2% to 90.4%) during the same time.31
Certification allows the employers to know that the nurses working for them have the knowledge and experience to work to promote optimal patient outcomes. Nurses who become certified have demonstrated their commitment to quality and to the profession. It can be assumed that if nurses have taken the time to become certified in a specialty, they intend to remain employed in an area where they can apply the knowledge. As such, certification sends a message of commitment to the employer. Certification also demonstrates to the employer that the nurses are taking responsibility for their own professional development. It has been suggested that organizations that support and recognize the value of certification may experience improved turnover and retention rates.39 Certification is also a means for hospitals to distinguish themselves from competitors.8,12
The ABNS conducted a national survey to assess perceived values and behaviors related to certification for nurse managers. Contrary to the findings reported in the AACN white paper, in this survey, there was no reported difference between certified and noncertified nurses regarding whether they were looking for a new employer or had any plans to make a job change.40 In other words, attaining certification did not necessarily translate into improved retention in a specific workplace.
As health care organizations apply to achieve Magnet designation by the American Nurses Credentialing Center, certification is one of the many important factors considered. Hospitals with a higher percentage of certified nurses are better positioned to achieve Magnet designation.28 In addition, hospital administrators must demonstrate to The Joint Commission that nurses are competent to provide care. Certification is a clear demonstration of the knowledge aspect of competency.8
As described earlier, Cary7 reported that certified nurses felt more competent in their skills, accountability, and confidence. Although these are perceptions, it is noted that perceptions can translate into job satisfaction and retention.7,8
Value to Nurses
Several actual and perceived benefits of certification to nurses themselves have been reported in the literature. A number of authors have reported benefits, including personal satisfaction, substantiation of attainment of specialty knowledge, increased professional credibility, evidence of commitment to nursing and the specialty, increased marketability, augmented salaries, and recognition from peers.5,11,40,41 Certification is greatly valued among nurses, including those who are certified, those who are not certified, and nurse leaders.40
The Perceived Value of Certification Tool (PVCT) is the primary instrument used in studies in this area. The attributes of this instrument are categorized in 2 ways—intrinsic and extrinsic rewards. Intrinsic rewards of certification are internal motivators for the individual nurse; external rewards are defined by others. Intrinsic factors delineated in the PVCT are enhanced feelings of personal accomplishment, personal satisfaction, validation of specialty knowledge, professional commitment, attainment of a practice standard, enhanced personal confidence in clinical abilities, evidence of accountability and level of clinical competencies, and enhanced professional autonomy. Extrinsic factors include recognition from peers, marketability, recognition from other health care professionals, recognition from employers, increased consumer confidence, and increased salary.34,40,42,43
It has been reported that attaining certification translates into a higher salary. Some hospitals recognize certification with a salary differential.12 Salary surveys conducted nationally have indicated that certified nurses have higher salaries than noncertified nurses. For example, in 2005, certified nurses reported earning $1 more per hour or 15% more annually than noncertified nurses.44,45 In 2006, a salary survey revealed that certified nurses earned $7300 more annually than noncertified nurses.46 In a 2008 salary survey, the majority of nurses with a salary range of $65000 to $120000 held specialty certification.47,48
The American Association of Occupational Health Nurses conducted a survey of its membership in 2005. Salaries of nurses certified in occupational and environmental health were significantly higher than salaries of those who were not certified.49 In 2004, it was reported that certified nurses earned approximately $10 000 more than their noncertified nurse colleagues.50 Similarly, AACN reported that 35% of nurses reported obtaining a higher salary because of certification.51
Conflicting data regarding increases in salary related to certification appear in the literature. In one study, only 21% of hospitals that were surveyed provided a salary differential for certified nurses.22 Furthermore, respondents to the Perceived Value of Certification study conducted by the ABNS did not universally agree that certification was associated with an increase in salary.40 In a subset analysis of the ABNS data set, only 40.5% of nephrology-certified nurses agreed that certification increased salary; 43.3% of nurses certified in any specialty agreed with that statement.52 Similarly, only a small number of perioperative nurses who participated in a Perceived Value of Certification study agreed that certification led to an increase in salary.34,43
Nurse Competence and Validation of Knowledge
It has been asserted that competency assessment based exclusively on success on a written examination may be a giant leap, as the latter may not translate to actual patient outcomes.53 Certification promotes continuing excellence in nursing, helping nurses achieve and maintain an up-to-date knowledge base in a specialty.7,42 In addition, it validates nurses' knowledge of the acute and critically ill to patients and families, to employers, and to themselves.
Many authors affirm that certification validates nurses' specialty knowledge and expertise.1,7,11,40,54–56 In a survey of more than 11000 nurses conducted by the ABNS, more than 90% of nurses who were surveyed concurred that certification validated knowledge in their specialty and indicated clinical competence.1
Nurses' perception of the relationship between specialty certification and nurse competencies has been evaluated in several studies.11,25,33,34,40,41,53,57–59 In one study, a relationship between certification and knowledge was reported. Nurses who were certified by the Wound Ostomy Continence Certification Board and the American Academy of Wound Management had higher knowledge scores than nurses who were not certified in that or other specialties. Certified nurses with other specialty certifications who were evaluated in this study included those having medical/surgical, oncology, and geriatrics certifications.21
In an earlier study that compared certified and noncertified nurses, findings suggested that certified nurses performed better in the areas of teaching/collaboration and planning/evaluation. Ratings were inconsistent, however, among the staff and supervisory nurses; only the latter group reported differences between certified and noncertified nurses. No differences in job performance were reported between certified and noncertified nurses in this study.6
Coleman and associates26 reported that certified nurses attained higher scores on 2 knowledge assessments than noncertified nurses. Redd and Alexander6 studied certified and noncertified nurses. Of those who were certified, 12.5% reported increasing their knowledge in the specialty as one of the reasons they sought certification. In the study conducted by the ABNS, 88% of the nurses surveyed concurred that certification augmented their confidence in their clinical abilities.1
Conversely, although data from the ABNS and other studies support that nurses who are certified have demonstrated specialty knowledge, of the nurse managers who participated in this latter study, only 18% felt that certified nurses made fewer errors.57 Results of another study showed that nurses who were certified in oncology obtained higher scores on the Nurses' Knowledge and Attitude Survey Regarding Pain.60 However, it did not suggest a relationship between certification and perception that attaining certification augmented knowledge and skills. It should be understood, however, that perception and actual outcomes do not necessarily correlate.
Researchers have found that certified nurses have higher perceptions of empowerment. They have suggested that the enhanced empowerment may improve work effectiveness. Results of several studies suggest a relationship between certification and levels of nurse empowerment.7,11,34,40,43,57,58,61 “Individuals with high degrees of formal and informal power have increased access to job-related power and opportunity structures in the organization. Degree of access to these empowerment structures increases the employees' level of self-efficacy, motivation, commitment, and ultimately, work effectiveness.”11(p277)
Significant differences in empowerment have been found between nurses who were certified and those who were not certified.61 The data revealed that certified nurses had significantly higher levels of empowerment than their noncertified counterparts.11,61 Researchers suggested that nurses with higher levels of empowerment to do their job may be more likely to stay employed at a facility.11 One study did not support this relationship.60
Personal Accomplishments and Satisfaction
Researchers who studied nurses who are certified and those who are not certified report that both groups of nurses perceive certification to augment feelings of personal accomplishment.4–7,26,33,40,54,58,60 These findings were corroborated by Dybec,14 who reported data from a collaboration study conducted between the Plastic Surgical Nursing Certification Board and the Nurse Credentialing Research Coalition.
One of the intrinsic reasons for attaining certification that has been delineated in the PVCT includes imparting a sense of pride that can lead to self-satisfaction.55 An AACN survey revealed that most nurses who sat for certification examinations did so for personal fulfillment and commitment to excellence in practice.62 Results of this survey also revealed that recently certified CCRNs and PCCNs strongly agreed that certification demonstrates pride.50 Similarly, Schmalenberg and Kramer32 reported a difference in global job satisfaction among nurses who were certified and those who were not. Redd and Alexander6 reported that certified nurses had higher self-esteem scores.
Conflicting data exist regarding the relationship between certification and professionalism. “Professionalism incorporates attitudes representing levels of identification with and commitment to a particular profession.”54(p252) Certification provides nurses with a sense of professional pride and achievement.3 The perceived value of certification with regard to professional growth applies to many nursing specialties.33
The National League for Nursing affirms that “certification in any field is a mark of professionalism.”63 This assertion is reiterated by several specialty organizations, such as the Hartford Institute for Geriatric Nursing, the American Board of Managed Care Nursing, the Association of Rehabilitation Nurses, and the Board of Certification for Emergency Nursing.64–67 Certified nurses felt that certification indicated professionalism39 and reported a higher level of professional practice.60 A noted limitation of this and other studies using survey methodologies is the need for more data that suggest a relationship between certification and enhanced clinical practice.23
Wynd54 studied a random sample of RNs in Ohio. In this study, nurses who were certified scored significantly higher on total professionalism and autonomy than noncertified nurses. Factors contributing to nursing professionalism were reported. Cary reported that nurses felt certification helped toward overall progress as “practice professionals.” 7(p50)
These latter findings corroborate findings from the 1999 collaborative study that was conducted between the Plastic Surgical Nursing Certification Board and the Nurse Credentialing Research Coalition. This American Nurses Credentialing Center–supported study revealed that certified nurses had higher patient satisfaction ratings and more effective communication and collaboration with other health care providers.14
It is believed that certification impacts the degree of recognition given to nurses by stakeholders (eg, patients, peers, and employers).5,40,43 Certified nurses can anticipate increased recognition from peers and employers. Recognition for attaining specialty certification has been reported in the form of public acknowledgment and bonuses from facilities.51
Byrne and colleagues43 found that 90% of nurses attained certification for a number of extrinsic rewards. One of these extrinsic incentives identified was recognition from peers. Similarly, of more than 11 000 nurses who participated in the ABNS study, more than 80% agreed that certification was associated with peer recognition.1
Results evaluating the relationship between certification and meaningful recognition are conflicting. Biel42 reported data from a national study of the perceived value of specialty certification of infusion nurses. Differences between certified and noncertified nurses were noted. Specifically, in this study, noncertified nurses did not agree that certification was valued by other stakeholders (eg, peers, colleagues, employers, and the public).
Data from a study of nurse managers conducted by the ABNS revealed that 86% of the managers would hire a certified nurse over a noncertified nurse if all other factors were equal.58 In another study, 90% of nurses reported that they attained certification for several reasons, one of which was marketability.43 In addition to identifying higher salaries, Cary7 reported a higher chance for promotion as a benefit of certification.
An RN license signifies that a nurse has acquired the necessary entry-level knowledge and skills to care for patients. On the basis of this licensure, nurses are considered prepared to manage general care responsibilities. Certification, on the other hand, provides substantiation that the nurse has attained specialty knowledge, experience, and clinical judgment and implies competency. Health care organizations seek to hire nurses with demonstrated competence.
Specialty certification is promoted for consumer protection. Many stakeholders can potentially benefit from certified nurses' knowledge. In addition to the 3 stakeholders discussed in this article (patient/family, nurses, and employers), other potential stakeholders who may benefit from nurse specialty certification include educational organizations, government agencies, and regulatory bodies.
As patients' conditions become more complex, the challenge for hospitals to promote patient safety and provide quality care increases. Certification in a specialty may be one way to help ensure these outcomes.
Although it is suggested that certification reflects competency, this relationship is not universally agreed on; strong consistent data to support this relationship are lacking. What is needed is consistent validation that certification reflects competency and has a direct positive impact on patient outcomes. This direct relationship will continue to be challenging to quantify as many other variables impact patient outcomes.
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certification; consumer protection; nurse satisfaction; patient outcomes; patient satisfaction