The first specialty certification in nursing was established in the United States in 1945.1 There are currently over 180 specialty certification options for nurses.2 Professional certification is a measure of distinctive nursing practice. It validates advanced knowledge in a specialty and implies ongoing high achievement through recertification.3 This has a positive effect on the quality of patient care, demonstrates value to healthcare stakeholders, decreases nursing turnover and vacancy rates, and increases patient satisfaction scores.4 Among certified nurses, 95% report a change in their nursing practice after becoming certified.4 Nurses believe that they experience fewer adverse events and errors after certification, which benefits the employing organization.5
Based on these observations, nurse managers prefer to hire nurses who've achieved specialty certification.4 However, in most healthcare institutions, specialty certification is a voluntary and self-directed endeavor.5 It's important to recognize that the perceived value of certification influences nurses' decision to pursue the credentialing process.6 The overall objectives of this project were to learn nurses' perceived value of certification and promote the professional development of clinical nurses through specialty certification by minimizing known and perceived barriers.
Interest in specialty certification increased at this institution in 2011, with the advent of officially recognizing and celebrating the American Nurses Credentialing Center's Certified Nurses Day. This celebration occurs on March 19 to honor the birthday of the late Dr. Margretta “Gretta” Madden Styles, who was a pioneer in nursing certification.7 At this institution, nurses are certified in over 40 nursing specialties, which are celebrated annually in March.
As this 210-bed Midwestern community hospital began its Magnet® journey, members of the nursing education department wanted to identify nurses' awareness of specialty certification and their barriers to becoming certified, and determine how nurses feel about specialty certification. Nursing professional development (NPD) specialists are often expected to promote certification, provide resources and review classes, and answer nurses' questions about the certification process. A review of the literature prompted an inquiry into nurses' perceived value of certification at this institution to enhance the NPD specialists' ability to meet nurses' needs along their path to certification.
In 2003, the Perceived Value of Certification Tool (PVCT) was developed to measure nurses' perceived value of certification.8 The tool was tested on 1,367 OR nurses, who identified three value factors: personal value, recognition by others, and professional practice.5 Since the creation of this tool, it's been used in multiple studies involving perioperative, infusion, pediatric, medical-surgical, and hospital-based nurses. The largest study using the PVCT was conducted as a national survey, with over 11,000 respondents.9 Using the results of the literature review, a replication study was conducted on board-certified and noncertified nurses' perceptions of certification value at this institution.
All hospital-based nurses were e-mailed an electronic link to the 18-item PVCT from the Competency and Credentialing Institute after permission was obtained for use. When completing the PVCT, respondents select their level of agreement on a 5-point Likert scale from 1 (strongly disagree) to 4 (strongly agree), with 0 indicating no opinion. Included with the tool were questions regarding demographic data and barriers to obtaining specialty certification that nurses experienced. The completion of the survey implied consent for participation. Permission from the hospital's Institutional Review Board was obtained.
There was a 32.5% participation rate, with 232 responses out of 713 eligible nurses. 61.6% of the nurses had specialty certification (n = 143), whereas 38.4% didn't (n = 89). Of the 89 noncertified nurses, there were 25 nurses who weren't yet eligible to take a certification exam because they hadn't completed the required hours of experience in their specialty. The hospital nurse certification rate at the time of the study was 47.1% based on 2015 National Database of Nursing Quality Indicators® data.
Demographic data included age, highest level of nursing education, and leadership or nonleadership role. Age demographics were categorized by generation, with generation Y being ages 20 to 35; generation X, ages 36 to 51; baby boomers, ages 52 to 69; and veterans, older than age 69. The majority of study participants classified themselves as generation X (44%). Most of the participants had a BSN degree as their highest level of nursing education (67%) and were in nonleadership roles (74%). (See Table 1.)
Certified and noncertified nurses were compared regarding their perceived intrinsic and extrinsic values of certification. For percent agreement, nurses who agreed or strongly agreed were grouped for each of the PVCT items. The percent agreement of respondents in the certified and noncertified nurse groups is shown in Table 2. Of those certified, more than 95% felt that certification intrinsically shows personal accomplishment, validates knowledge, provides personal satisfaction, indicates professional credibility, and offers a professional challenge. Those nurses not certified agreed with these statements at a lower level (78.7% to 87.6%).
Extrinsically, certified nurses rated increased marketability and employer recognition as the greatest benefits of certification at 95.1%, whereas noncertified nurses agreed, but with lower percentages of 86.5% and 84.3%, respectively. When the results of this study were compared with a previous study using the PVCT instrument at a Magnet organization, it was found that this institution's nurses had similar overall perceptions of the intrinsic and extrinsic value of certification.5
For certified nurses at this institution, the intrinsic values that scored the lowest were: enhances autonomy (83.9%), level of competency (90.9%), and shows evidence of accountability (90.9%). These were also the three lowest scores for noncertified nurses. For the extrinsic values, certified nurses scored lowest in: increases consumer confidence (77.6%) and professional recognition (82.5%). Noncertified nurses scored lowest in: increases consumer confidence (61.8%), peer recognition (65.2%), and increases salary (68.5%).
The top barriers to becoming certified were identified as not having enough time to prepare for the exam (n = 32), the cost of the exam (n = 27), test-taking anxiety (n = 23), lack of employer rewards (n = 16), fear of failure (n = 16), and cost of the continuing education needed to maintain certification (n = 16). (See Table 3.)
Overcoming perceived barriers
Certified nurses as a group placed higher values on certification than those who weren't certified, which is consistent with the literature. Intrinsic values are more challenging to influence and may naturally improve after certification has been achieved. Therefore, focus should be on the extrinsic values noted by noncertified nurses, such as increasing employer and peer recognition, professional recognition, marketability awareness, consumer confidence, and salary.
The main barrier to achieving certification was time. This is difficult to overcome because an NPD specialist can't create more time for staff. Scheduling dates to prepare through study groups or having review classes at the facility may assist staff members to make time to study for certification. The NPD specialist may also offer education on creating habits to help staff members incorporate study time into their daily schedule. For example, using a stacking technique such as adding the new desired habit (studying) to an existing habit (reading the news).10
The second highest perceived barrier was exam cost. This institution currently offers financial incentives for preparation and prepayment or reimbursement upon successful certification with a maximum cap. Education needs to be provided to increase awareness of this benefit to decrease the resistance to certification due to cost. Along with the cost of the exam, the fear of failure barrier can be overcome by increasing the awareness of programs provided by certification boards that allow employers to offer the exam free of charge to employees with one retake opportunity. Examples of these programs include the Medical-Surgical Nursing Certification Board FailSafe Certification Program, Oncology Nursing Certification Corporation FreeTake, and Pediatric Nursing Certification Board No Pass, No Pay Certification Support Program. Benefits of these programs include decreasing nurses' test-taking anxiety and removing the financial burden of paying a test fee upfront.11 Although not all specialty certifications offer programs like these, this institution offers the available programs. For other specialty certifications, this institution will also continue to provide prepayment for the exam and preparation, along with partial payment for maintenance recertification continuing education. The NPD specialist can improve employee education related to the available options to further remove barriers to taking exams.
For the next barrier of test-taking anxiety, the NPD specialist can help reduce anxiety by providing preparation tools, strategies, and test-taking tips through educator-led workshops. The perceived barrier of lack of reward can be overcome by increasing awareness of the rewards offered by this facility. Certified nurses are given a raise and a recognition pin. In addition, they're invited to an annual celebration during Certified Nurses Day and Nurses Week, and receive personal recognition from the CNO. Other rewards that may be added to improve perceived value include additional hospital-wide or unit-based recognition throughout the year and a yearly bonus for maintaining certification.4
Implications for nurse managers
The findings of this study are limited to one community hospital in the Midwest and may not reflect the values of nurses in other institutions. However, the perceived value of certification at this institution is similar to a Magnet institution that was previously studied.5 In order to meet the goal set for certification, efforts should focus on the intrinsic and extrinsic values of noncertified nurses. Extrinsic rewards may have a larger influence on nurses' initial certification decision. Nurse managers should focus efforts on professional recognition, peer acknowledgment, and consumer feedback. If the extrinsic value of increased salary is already offered, efforts should be placed on increasing awareness of this benefit.
Reaching the goal
Overall, the certified nurses at this institution have a higher percent agreement with the intrinsic and extrinsic values of certification. The noncertified nurses had a notably lower percent agreement in both categories. Based on these results, NPD specialists put together a plan to overcome the perceived barriers to certification to improve noncertified nurses' perception of certification value and, ultimately, assist them in becoming certified in their specialty.