Sayre, Cindy MN, ARNP; Wyant, Sheri MSN, RN, OCN; Karvonen, Colleen MN, RN, CMSRN, CWON
Cindy Sayre, MN, ARNP, is Medical-Surgical Clinical Nurse Specialist, Patient Care Services, University of Washington Medical Center, Seattle, Washington and currently Director of Professional Practice and Patient and Family Centered Care, University of Washington Medical Center.
Sheri Wyant, MSN, RN, OCN, is Pain Management Clinical Nurse Specialist, Patient Care Services, University of Washington Medical Center, Seattle, Washington.
Colleen Karvonen, MN, RN, CMSRN, CWON, is Wound Ostomy Clinical Nurse Specialist, Patient Care Services, University of Washington Medical Center, Seattle.
This research was made possible by Grant D11HP03123-01-00, "Expanded Practice in Medical-surgical Nursing," Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services.
ADDRESS FOR CORRESPONDENCE: Cindy Sayre, MN, ARNP, Patient Care Services, University of Washington Medical Center, 1959 NE Pacific Ave, Seattle, WA 98195 (e-mail: email@example.com).
Certification has been defined 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" (American Board of Nursing Specialties, 2005). Nursing certification has been shown to be important for protecting the public (Cary, 2001) and distinguishing nursing practice. Certification is a means by which nurses show their commitment to patients and to lifelong learning. Certification benefits the individual, the profession, and the public through promotion of quality patient care, expanded career opportunities, and increased self-esteem and satisfaction. Medical-surgical nursing certification is available through the American Nurses Credentialing Center (ANCC) and the Academy of Medical Surgical Nurses.
Cary (2001) studied more than 19,000 certified nurses from across the United States and Canada. The study was the first to elucidate the perceived benefits of certification as reported by nurses who were certified. Some of the benefits which were cited include "feeling more confident in my ability to detect early signs and symptoms of complications in my patients" and being able to "initiate early and prompt interventions for patients experiencing complications." An interesting finding was that the nurses who were most recently certified reported the greatest changes to their practice. Cary stated that these findings "provide initial evidence that certification may give nurses the means or opportunity to practice in a manner likely to improve outcomes."
Nurse educators and clinical nurse specialists at an academic medical center were interested in enhancing nursing practice for medical-surgical nurses and potentially improving patient outcomes. A 14-week medical-surgical certification and practice review course has been offered at the medical center since 2002. The course consists of 14 sessions, each lasting 3 hours. The classes include content from the core curriculum provided by the certifying bodies (see Table 1). The classes are didactic in format, with a 2- to 3-hour lecture and a facilitated test-taking session. Supplemental online content is available for participants including steps on applying for certification, nursing process, test-taking tips, research and quality improvement, discharge planning, and domestic violence. Participants are encouraged to share a written summary of a clinical example(s) that demonstrates the application of content from the class to a clinical event(s). The examples might include an event where the nurse believes that the intervention(s) really made a difference in a patient's outcome, an "aha!" experience, or the application of critical thinking to a complex case. Some clinical examples are shared each week with all the participating sites.
Further details about the course development are described in a previous article (Karvonen, Sayre, & Wyant, 2004). In 2005, in collaboration with the continuing nursing education department of the University of Washington School of Nursing, the course was expanded to include six sites from Washington and Alaska via videoconferencing. A total of 146 participants from all the sites were enrolled in the course. One hundred nineteen (82%) successfully completed the course. Participating sites were facilitated by an agency coordinator. Agency coordinators are educators and certified nurses who received additional training from the course planners. The agency coordinators meet for a full-day training session annually. One of the topics discussed is mentoring or coaching. For the purposes of this program, mentoring is understood to be a time-limited relationship wherein the coordinator assists the participant to identify potential barriers to success and collaborates with the participant in making a plan to address the barriers. Both the agency coordinator workshop and the medical-surgical certification and practice review course were supported in part by funds from a training grant from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services.
The national certification examination pass rate for participants from the 2005 medical-surgical certification and practice review course was 86%. Statistics provided by the ANCC demonstrate a national pass rate of 71.7% for all baccalaureate-level and higher level specialty examinations combined and 64.6% for all diploma- and associate-degree-level specialty examinations combined. Statistics were not available from the Academy of Medical Surgical Nurses. Anonymous demographic data were collected from the course participants on the first day of class. The collected demographic data are summarized in Table 2.
In previous years, participants described unanticipated benefits from the course such as enhanced self-confidence, competence, and initiative. Course facilitators also noted enhanced leadership qualities in those who participated. For the purposes of this study, participants were asked to reflect on the impact of the course on their self-confidence, competence, leadership, and initiative.
REVIEW OF THE LITERATURE
Nursing certification has been shown to have many potential benefits, including personal and professional growth, professional recognition, and increased opportunity for career advancement (Cary, 2001; Prowant et al, 2007). The four benefits selected for this study included the qualities of self confidence, competence, leadership, and initiative. A review of the literature to identify standardized definitions for each of the qualities was completed.
Self-confidence is defined for the purpose of this study as the belief in yourself that you know what to do to provide nursing care. A literature review did not reveal any standardized definitions of self-confidence in nursing. Many articles interchange the terms self-confidence and self-efficacy. Bandura (1986) defined perceived self-efficacy as a belief in one's capabilities to organize and execute the course of action required to attain a goal. The underlying premise of self-efficacy is self-regulation of behavior by cognitive, affective, and motivational processes. Bandura's self-efficacy construct includes a broader scope of behavior than that of the term self-confidence. Several self-confidence scales are reported in the literature, but none are specific to the content of interest for this study.
Competence is defined in the dictionary (http://dictionary.reference.com/browse/competence) as possession of required skill, knowledge, qualification, or capacity to perform a certain task. It can encompass one's knowledge, skills, and behaviors. Nursing competence was defined for this study as being "effective, capable and skilled to provide nursing care." This definition is consistent with del Bueno's (2001) definition of competence: the "ability to meet job expectations and subsequent continuous effective care for assigned patients."
Leadership is defined as the ability to positively influence others in the provision of patient care. This definition is consistent with Cook's (1999) definition of a leader as "an expert clinician, involved in providing direct clinical care, who influences others to continuously improve the care they provide."
Initiative is defined as the power to begin a process to improve patient care. Initiative allows an individual to identify problems and implement solutions. A literature review did not reveal any standardized definitions of initiative. Anecdotal examples from students in the review course include the following: A nurse in the 2004 class decided to learn dialysis after taking the course; prior to the class, she did not think she could do it. In the 2005 class, a nurse helped change a standardized order set after learning about the indications for the various IV fluids.
A research proposal was submitted and approved by the institutional review board. A descriptive survey was developed and reviewed by expert medical-surgical nurses for face validity.
The survey tool included two sections: a 5-point Likert scale and an open-ended question. Participants were asked to read the definitions for each domain provided (see Table 3) and to rate the degree to which the course affected their medical-surgical nursing practice using the definitions for self-confidence, competence, leadership, and initiative.
The second section of the survey was structured to elicit a written example of the impact of the course on nurses' medical-surgical nursing practice. The survey included this question: "Provide a brief example of how your participation in the medical-surgical certification review course has affected your medical-surgical nursing practice." Space was provided for the participants to write their responses, including the back of the survey page.
The sample was composed of registered nurses (n = 119) who completed ≥80% of the review course offered in 2005. These nurses were employed in the states of Washington and Alaska.
An anonymous survey including an introduction cover letter was mailed 4 months after the conclusion of the course to all course participants who completed 80% or more of the course. A follow-up reminder letter was sent 2 weeks later. The surveys were mailed back to a central nursing office where an administrative staff member not associated with the study opened them. The surveys were placed in a blank envelope for the researchers.
The Likert-scale data were summarized using percentage of response for each concept. The written examples were analyzed using content analysis. Downe-Wamboldt (1992) described the content analysis research method as generally encompassing the following with the goal of external validity: selecting the unit of analysis, creating and defining categories, pretesting the category definitions/rules, assessing reliability and validity, revising the coding rules as needed, pretesting the revised categories, coding the data, and reassessing reliability and validity. All of the written examples were reviewed by the researchers to identify mutually exclusive themes (entire ideas or thoughts). A set of rules for classification of the themes into categories was developed and tested on a sample of written responses by the researchers and revised. The researchers then used the revised rules to independently code the data. In addition, another nurse researcher, skilled in qualitative research methodologies and content analysis, was asked to participate in the coding process. Comparison of results demonstrated strong agreement (100%) between the coders with both the second and third rating rounds.
Surveys were returned by 39 of the 119 nurses sampled, representing a 33% return rate. Thirty-eight nurses responded to the Likert scale question, "Participation in the medical-surgical certification review course had a positive effect on my medical-surgical nursing practice in the following areas: self-confidence, competence, leadership, and initiative."
Survey results demonstrated a positive effect on the nurses' self-confidence (87%), competence (82%), leadership (60%), and initiative (82%) (see Figure 1). 76% of participants agreed that the course positively affected all four qualities. Five of the participants (13%) strongly agreed that they experienced a positive effect on their medical-surgical practice for all four concepts.
Three participants responded that the course had no effect on the four domains tested. One participant disagreed that participation in the course had a positive effect on competence and leadership. This same respondent agreed that the course had a positive effect on initiative.
Using content analysis as described by Downe-Wamboldt (1992), the written exemplars were rank ordered into seven theme categories (see Table 4).
The exemplars demonstrated the efficacy of the course in the domains of knowledge acquisition and validation, enhancement of confidence, and the ability to contribute to collegial discussions. Nurses became a resource for their peers and were inspired to strive for more. Some, however, remained unconvinced about the benefits of certification.
Survey results are consistent with the previous findings of Cary and Prowant et al. The study found that nurses who prepared for certification reported both increased confidence and increased competence in their role as nurses. This led to enhanced collaboration, which has been found to improve patient outcomes (Baggs, 1992). Survey comments such as, "The course broadened my knowledge base, I am more willing to participate in troubleshooting with doctors and fellow co-workers" and "The med-surg course improved my competence and in turn helped me be a better nurse and give better care to my patients," speak clearly of the impact of the course. A clinical example shared during the course exemplifying this is the following:
Following the neurology session I had a patient post stroke with elevated blood pressure. The nurse I got report from did not understand why the parameters for giving hydralazine were so high. I was able to use the information from this class to explain why they wanted her blood pressure to be higher than normal and to have a much better understanding of her care issues.
It could be argued that the nurses in the study were a motivated group based on their commitment to taking on and completing at least 80% of a 14-week certification review course. Therefore, these participants may have grown personally and professionally even with a different review model. In addition, the mentoring and coaching that participants received as individuals and as a group may have contributed to their success. The effect of mentoring and coaching was not studied. As the course progressed, so did the sense of community within the group. This may have affected the participants but was not studied. Some of the participants were mandated by employers to complete the course which may have affected their overall level of satisfaction with the course. Finally, content analysis methodology is limited to only the written communication provided, and there are limited types of statistical analysis that may be applied to the data.
Participation in the medical-surgical certification review course had a positive effect on medical-surgical nursing practice for the concepts of self-confidence, competence, leadership, and initiative for most participants responding to the survey. These results demonstrate successful achievement of the ultimate goal of staff education to see nurses translate newly acquired knowledge into practice, thus enhancing the quality of patient care.
The authors wish to thank to Kristen Swanson, PhD, RN, FAAN, and Elizabeth Bridges, PhD, RN, CCNS, for their assistance with data analysis.
© 2010 Lippincott Williams & Wilkins, Inc.