NURSING SPECIALTY CERTIFICATION AND NURSING-SENSITIVE PATIENT OUTCOMES IN THE INTENSIVE CARE UNIT. Challenges in the Critical Care Workplace. 1.

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1 Challenges in the Critical Care Workplace NURSING SPECIALTY CERTIFICATION AND NURSING-SENSITIVE PATIENT OUTCOMES IN THE INTENSIVE CARE UNIT By Greta Krapohl, RN, MSN, Milisa Manojlovich, RN, PhD, CCRN, Richard Redman, RN, PhD, and Lingling Zhang, MA C E 1.0 Hour Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Understand the association between intensive care units with a higher proportion of certified nurses and perceptions of the workplace empowerment. 2. Describe pertinent research examining the relationship between nursing specialty certification and patient outcomes. 3. Recognize that fostering an empowering workplace environment may enhance the rate of nursing specialty certification. To read this article and take the CE test online, visit and click CE Articles in This Issue. No CE test fee for AACN members American Association of Critical-Care Nurses doi: /ajcc Background To the public and to individual nurses, certification usually means expert, high-quality, competent nursing care. Little research, however, has yielded results that support, or refute, any differences in clinical practice between certified and noncertified nurses. Objectives To determine whether the proportion of certified nurses on a unit is associated with the rate of nurse-sensitive patient outcomes. Methods A nonexperimental, correlational, descriptive design was used to anonymously survey 866 nurses working in 25 intensive care units in Southeast Michigan.The Conditions for Work Effectiveness Questionnaire-II was used to measure workplace empowerment, and an additional question was asked about certification status. Outcome data were simultaneously collected on 3 nurse-sensitive patient outcomes: (1) rate of central line catheter-associated blood stream infection, (2) rate of ventilator-associated pneumonia, and (3) prevalence of pressure ulcers. Data were aggregated and analyzed at the unit level. Results No significant relationship was found between the proportion of certified nurses on a unit and patients outcomes. The association between nurses perception of overall workplace empowerment and certification, however, was positive and statistically significant (r =.397, P =.05). Conclusions Although a link between certification and nursesensitive outcomes was not established, the association between workplace empowerment and the proportion of certified nurses on a unit underscores the importance of organizational factors in the promotion of nursing certification. (American Journal of Critical Care. 2010;19: ) 490 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6

2 Specialty nursing certification is often equated with expert, high-quality, competent professional nursing practice. It is defined as a voluntary practice that provides formal recognition of specialized knowledge, skills, and clinical practice experience beyond the requisite mandatory and regulatory minimal requirements of licensure. 1 According to recent estimates, registered nurses in the United States were potentially eligible for more than 115 different nursing specialty certifications through 45 nursing and interdisciplinary organizations. 2-4 Despite the long-standing perception of certification as a synonym for high-quality nursing care, little research has yielded results that support any differences that may exist between certified and noncertified nurses in relation to the quality of clinical practice or patient care outcomes. Because nursing specialty certification is intended to enhance the knowledge and overall competence of nurses, it is plausible that a measurable difference in nursing care is delivered by certified versus noncertified nurses. Finding a link between nursing-sensitive patient outcomes and specialty certification, therefore, could demonstrate the importance of nursing specialty certification in direct patient care. The ambiguity surrounding the word certification and the variety of acronyms associated with certification can be a source of confusion for patients and for healthcare professionals. 4,5 Does certification denote expert clinical knowledge or set minimal standards? What do those letters after registered nurse (RN) signify? Is certification voluntary or mandatory? The first portion of this section aims to clarify the current terminology surrounding nursing certification. The next portion outlines pertinent research in the past decade examining the relationship between nursing specialty certification and patient outcomes in order to appreciate the gaps in the literature and the state of the science in this realm. Table 1 Licensure vs certification Licensure Derived from Latin words: licentia (freedom, liberty) and licere (practice) 5 Gives permission to practice 5 Awarded through state board of nursing Mandatory (legal requirement) Minimal standards achieved for entry into practice Certification Derived from Latin words: certu (certain) and facere (to make) 5 Conveys belief and trust 5 Awarded through nongovernmental professional nursing and interdisciplinary associations Voluntary Adds to assurance of public safety Definition of Terms Licensure, Certification, and Accreditation To understand certification, it is necessary to differentiate among the terms licensure, certification, and accreditation because these terms are often confused. Licensure and certification both are awarded to individuals, so they are best viewed in contrast to one another (Table 1). Accreditation is bestowed upon organizations. About the Authors Greta Krapohl is a doctoral candidate, Milisa Manojlovich is an assistant professor, and Richard Redman is a professor and assistant dean of graduate programs at the University of Michigan School of Nursing in Ann Arbor. Lingling Zhang was the lead statistician at the Center for Statistical Consultation and Research when this article was written. Corresponding author: Greta Krapohl, RN, MSN, University of Michigan School of Nursing, 400 N Ingalls, Room 1160, Ann Arbor, MI ( krapohlg@umich.edu). Unlike licensure or certification, accreditation is targeted at the organizational level, not the individual level. The Institute for Credentialing Excellence (formerly the National Organization for Competency Assurance) is the umbrella organization for the accreditation body, the National Commission for Certifying Agencies. 6 The National Commission for Certifying Agencies is a global leader in the accreditation of professional certification organizations 4 and has accredited several specialty nursing certification agencies. 7 In response to the dramatic growth in the number of nursing specialties and the unrestrained escalation in the number of certifying agencies, an accreditation body dedicated specifically to the nursing profession was chartered in The American Board of Nursing Specialties (ABNS) is a national, not-for-profit organization governed by elected nursing representatives who maintain the AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No

3 Certification is equated with expert, highquality, competent professional nursing practice. Little research has linked nursing specialty certification with enhanced patient outcomes. ABNS as an umbrella organization for accreditation of nursing specialty certifying organizations in the United States. This model of governance is similar to the governance models of the medical, dental, and pharmacy health care professions. 9 Currently, 16 nursing specialty organizations have more than 40 examinations accredited under the ABNS. 10 Nursing Specialty Certification and Workplace Empowerment Workplace empowerment is defined as 4 contextual factors opportunity, information, support, and resources embedded in the work environment that, when accessed, result in workers feeling good about what they do and satisfied in their roles Results of earlier studies link workplace empowerment with characteristics of professional nursing practice such as higher levels of job satisfaction, 14,15 communication, 13 and an enhanced patient safety climate. 16 Because workplace empowerment has been associated with positive characteristics of professional nursing, it is not surprising that a recent study showed a higher perceived level of empowerment in certified nurses than in noncertified nurses (P <.008). 17 Although this study was limited to only one institution, it appears to have formed the groundwork for investigating the relationship between workplace empowerment and specialty nursing certification. It remains unclear, however, whether the perception of workplace empowerment stimulates certification or certification facilitates workplace empowerment. Nursing Specialty Certification and Patient Outcomes Several descriptive and comparison studies have linked certification with nurses perceptions of personal growth, 18 increased competence and confidence, 18,19 enhanced knowledge, 20 and self-esteem 21 ; however, little research has linked nursing specialty certification with enhanced patient outcomes. Of the 150 nursing publications listed on the comprehensive and up-to-date bibliography of articles specific to nursing specialty certification on the ABNS Web site, only 5 were categorized under the subheading of patient outcomes. 22 Similarly, a recently published review of the literature 23 mentioned only 2 research studies on nursing specialty certification and measures of patients outcomes. After a comprehensive search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) data base, 6 studies of nursing specialty certification and patient outcomes remained for analysis (research focused on the subcategory of advanced practice nurses and studies limited to self-reports of patient outcomes were omitted from this analysis; see Table 2). Because the research on this topic is just beginning to accumulate, comparisons and analysis of the few existing studies are challenging because of the multitude of patient outcomes selected for measurement, the different patient care settings (rehabilitation center, 24 operating room, 27 home care agency, 26 general hospital organization 25,28,29 ) and the focus on a particular specialty certification 24,26,27 versus a nonspecific certification analysis 25,28 (see Table 1). However, 2 important findings are evident from this aggregation of research and may suggest a promising link for further investigation in this topic area. The first is an association between the percentage of certified nurses in an intensive care unit (ICU) and a lower rate of reported patient falls. 29 The second is the finding of a statistically significant relationship between a unit s having a higher percentage of nurses who are certified rehabilitation registered nurses (CRRNs) and a decreased length of stay (LOS). 24 These findings both suggest that measurement of specific outcomes may be sensitive to nursing factors specific to the type of patient care environment examined. For example, LOS may be a sensitive indicator for the rehabilitation environment but not for the ICU environment. Additional research that is prospective in design and focused on one particular nursing specialty certification (versus nonspecific or generalized nursing specialty certification) and limited to one patient care environment (not a variety of different types of units), may reveal a link between nursing specialty certification and patient outcomes. Until then, the dearth of strong evidence in support of the association between certification and patient outcomes will hinder the momentum of strong initiatives to endorse certification as a means to enhance patient outcomes. Theoretical Framework The theoretical framework of this study was developed by using the structure-process-outcome model of quality care 30 and the theory of workplace empowerment. 12,31 The Donabedian 30 structureprocess-outcomes model of quality care served as the foundational context of the model, which portrayed a linear progression toward enhanced patient 492 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6

4 Table 2 Research studies examining nursing specialty certification and patient outcomes Title Design Certification type Results Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings 24 Prospective, observational (54 rehabilitation units) Certified rehabilitation registered nurse (CRRN) Statistically significant inverse relationship between the percentage of nurses with the CRRN and length of stay (LOS) (P.001); for every 1% increase in CRRNs, LOS decreased approximately 6% No statistically significant relationships between certification and medication error outcome measures The Relationship Between Nursing Specialty Certification and Medication Administration Errors and Incident Reporting 25 Retrospective (medication errors), descriptive, correlational, triangulated (500-bed military hospital) Retrospective, descriptive pilot study (large Midwestern home-care agency with 1178 admissions in a 1-year study period) Multiple Does Certification Status of Oncology Nurses Make a Difference in Patient Outcomes? 26 Oncology certified nurse (OCN) Symptom management: Statistically significant positive relationship between certification of nurses and documentation of postadmission fatigue assessments Incidence of adverse effects: Statistically significant inverse association between teaching of patients and number of infections in relation to certification status Episodic care utilization: No statistically significant findings No statistically significant relationships between a higher proportion of certified nurses and outcome measures (mortality, LOS, and complications) No statistically significant relationships were found between certification and outcome measures (falls, falls with injury, hospital-acquired pneumonia, hospitalacquired pressure ulcers) Statistically significant inverse relationship between the rate of falls and the percentage of certified nurses on a unit (P =.04); no other statistically significant findings for additional outcome measures (bloodstream infection, urinary tract infection, central catheter infection, skin breakdown, medication administration errors) Perioperative Nurses and Patient Outcomes Mortality, Complications and Length of Stay 27 Retrospective, descriptive, (32 hospitals in Maryland, totaling 1894 discharges) Perioperative nurse (CNOR) Relationships of Professional Nurse Characteristics and Nurse Staffing to Adverse Patient Outcomes 28 Retrospective, correlational, cross-sectional (18 medical-surgical units/3 hospitals) Multiple Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units 29 Retrospective, correlational, cross-sectional (48 units/29 hospitals) Multiple outcomes. Kanter s theory of workplace empowerment provided the key stimulus for certification achievement because of the empowerment that arises from the organizational environment. 12,31 According to this theory, 4 elements are necessary for empowerment to prevail: (1) opportunity for advancement, (2) access to information, (3) access to support for job responsibilities and decision making, and (4) access to resources required for the job. 12 We theorized that if the unit environment provided enhanced opportunities for challenging work, and supportive opportunities for growth of skills and knowledge on the job, a higher proportion of nurses would achieve and maintain certification. Because certification purports to enhance the knowledge base of nurses, we further theorized that certification would translate into better outcomes for patients. Although certification is more likely to be conceptualized as a structural variable, our model was purposefully designed to incorporate certification as a process variable to reflect the potential relationship with the quality of nursing care delivered (see Figure). Specialty certification requires a commitment to continuing education and practice, which are ongoing instead of episodic, and thus more consistent with a process concept. When viewed in this context, specialty nurse certification is a mediator of positive outcomes for patients. Objectives The purpose of this study was to determine if an association exists between the proportion of nurses on an intensive care unit who are certified and the rate of adverse outcomes for patients on that unit. The 2 research questions were as follows: AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No

5 Enhanced workplace empowerment Opportunity Information Support Resources Informal power Formal power Higher proportion of nurses with specialty certification Fewer adverse outcomes for patients Nurse-sensitive outcomes for patients Ventilator-associated pneumonia Central line catheter-associated blood stream infection Pressure ulcers Structure Process Outcome Figure Theoretical framework: nursing specialty certification and nurse-sensitive outcomes for patients. Is there an association between nurses perceptions of workplace empowerment (as measured by the Conditions for Work Effectiveness Questionnaire-II [CWEQ-II]) and the proportion of nurses with specialty certification on a unit? Is there an inverse association between the proportion of certified nurses on a unit and the rate of nurse-sensitive adverse outcomes for patients? Methods Design and Sample This study was a secondary data analysis of previous research investigating the relationship between nurses perceptions of nurse/physician communication, practice environment, and patient outcomes 13 that used a nonexperimental, correlational, descriptive survey design. Approval to reexamine the specific relationships of workplace empowerment, nursing specialty certification status, and nurse-sensitive patient outcomes was received from the institutional review board (medical) at the University of Michigan. The sample consisted of 25 adult intensive care units at 8 hospitals (Detroit Medical Center, Harper University Hospital; Detroit Medical Center, Detroit Receiving Hospital; St. John Hospital and Medical Center [Moross]; St. John Hospital, Macomb; St. John Hospital, Oakland; St. John Hospital, Providence; St. John Hospital, Riverview; University of Michigan Health System) in southeastern Michigan. For the primary study, all nurses employed at 1 of the 25 intensive care units were administered a series of questionnaires on the topics of workplace empowerment, practice environment, nurse-to-physician communication, and perception of patient outcome measures. This secondary analysis included the full complement of nurse survey responses from all participating intensive care units (n = 866). The sample population was limited to staff nurses only: no nurse managers, supervisors, or advanced practice registered nurses (APRNs) were included in the study. APRNs were omitted from the analysis because APRNs have tighter restrictions on certification oversight, validation procedures, and state regulations than do nurses with specialty nurse certification who do not hold advanced practice roles (or who are advanced practice but do not have direct care responsibility). 9 Procedure Along with the survey data, data were collected on patient outcome measures in each participating unit. Specifically, 3 outcomes were selected as dependent variables: (1) rate of central line catheterassociated blood stream infection, (2) rate of ventilator-associated pneumonia, and (3) prevalence of pressure ulcers. These measures were chosen because they are likely to be sensitive to nursing practice. 32 Data for outcome measures were collected by each respective institution in accordance with the standardized National Quality Forum definitions. 33 Instruments The original instrument questionnaires have been already described, 13 so only those portions of the questionnaires that are relevant to the secondary analysis are explained here. Data for workplace empowerment measures and certification status were culled from 2 portions of the original survey questionnaire: Workplace Empowerment. Laschinger s Conditions for Work Effectiveness Questionnaire-II (CWEQ-II) is a 6-subscale, 21-item measure of workplace empowerment. 13,34 The 6 subscales are Opportunity, Information, Support, Resources, the Job Activities Scale II (JAS II), and the Organizational Relationships Scale II (ORS-II). 34 The summation of all 6 subscales provides a total empowerment score ranging from 6 to 30. The Cronbach alpha was.92 for this analysis. Previous research using the CWEQ-II has reported reliabilities between.82 and ,16,35 Certification. The certification status of nurses was extracted from the demographic portion of the questionnaire. Nurses were asked to indicate whether or not they had specialty certification and, if so, in what area. Data Analysis Data were analyzed by using the SPSS statistical software program (SPSS Inc, Chicago, Illinois). 494 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6

6 Frequencies and descriptive statistics were used to describe the characteristics of the sample and to look for violations of independent sample and outliers. After examination of the data for all variables, a new data set was developed with variables aggregated to the unit level. Survey data on certification status were reduced to the proportion of nurses on a unit. Empowerment scores were aggregated by units mean scores. The nurse-sensitive patient outcome data for all 3 outcomes (rate of central line catheter-associated blood stream infection, rate of ventilator-associated pneumonia, and prevalence of pressure ulcers) were preserved as originally collected at unit level analysis. Results Of the 866 surveys distributed, 462 surveys were completed and returned. 13 After surveys with missing certification information were excluded, 450 surveys were included for final analysis. The response rates from each unit ranged from 6% to 100% for a mean of 57%. By using elements of Dillman s Tailored Design Method, the investigator was able to nearly double the average response rate for mail-in surveys of 20% to 30%. 36 Nurses working on the units had a mean of 13 years of nursing experience and a mean of 50% of the nurses in each unit were prepared at the baccalaureate level of education. The mean rate of specialty certification in a unit was 17%, with a range from 4% to 38%. The total association between nurses perception of overall workplace empowerment and certification was positive and statistically significant (r =.397, P =.05), providing support for the first research question. A separate analysis of each of the 4 subscales revealed a strong, positive and statistically significant relationship between nurses perceptions of resources (r =.503, P =.01) and specialty certification and a moderately strong and positive relationship between nurses perception of support (r =.407, P =.04) and specialty certification. The proportion of nurses with specialty certification in each unit also bears a moderate and marginally significant association with information (r =.390, P =.05). However, no association was found between nurses perception of opportunity (r =.296, P =.15) and the proportion of nurses who were certified on a unit. Likewise, on the additional dimensions of the JAS II (measuring access to formal power structures), and the ORS-II (measuring access to informal power), no association between these measures and the proportion of certified nurses was found. The additional variables of a nurse s educational preparation or experience level were also analyzed but did not show any appreciable association with the proportion of nurses certified on a unit. An unexpected finding was a strong, statistically significant, inverse association between nurses perceptions of empowerment and their reported experience level (r = -.505, P =.01). In answer to the second research question, no statistically significant relationship was detected between the proportion of certified nurses on a unit and any of the 3 nurse-sensitive patient outcomes. Although the proportion of certified nurses showed an inverse relationship to the prevalence of pressure ulcers and the rate of central line catheter-associated blood stream infection, the relationship was weak and statistically insignificant. The rate of ventilatorassociated pneumonia showed a marginal positive direction but that association was not statistically significant either. Discussion The purpose of this study was to determine if an association exists between the proportion of nurses certified on an intensive care unit and the rate of adverse outcomes for patients. The first research question, validating the first portion of our theoretical framework, revealed a positive association between nurses perceptions of workplace empowerment (as measured by the CWEQ-II instrument) and the proportion of nurses with specialty certification on a unit. A clear answer to the second research question, testing an association between the proportion of certified nurses on a unit and the rate of adverse nurse-sensitive outcomes for patients, remained intangible. The most interesting finding of this study was a positive association between workplace empowerment and certification. This finding is consistent with results of other studies that showed higher levels of perceived workplace empowerment among nurses and the presence of positive professional nursing attributes Furthermore, results of earlier studies support our finding of higher empowerment scores in certified nurses than in their noncertified counterparts. 17 Taken together, all of this evidence suggests support for Kanter s theory of workplace empowerment, which contends that work behavior is driven by responses to work conditions rather than by inherent personality traits. 37 Although our investigation revealed higher overall empowerment scores in units with a higher There was a positive relationship between certification and perception of empowerment. AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No

7 Work behavior is driven by responses to work conditions rather than by inherent personality traits. proportion of certified nurses, the breakdown of the individual subscales of resources and support of the CWEQ-II were identified as the primary drivers behind the attainment of the higher scores. After reexamination of the 6 specific questions related to these subscales, we propose these subscales may have emerged as the most important because of strong unit leadership, the availability of certification resources, and the support of nursing continuing education. Although Piazza and colleagues 17 reported higher scores of certified nurses on the subscales of information, formal power, and informal power, their study included a broader nursing population (not only staff nurses) and was analyzed at the organizational level of analysis, 2 factors that may have influenced subscale differences. Despite this variation, it appears that certification was a consequence of workplace empowerment, not the cause of it, which gives further support for certification as a process component in the delivery of nursing care. Puzzling as it may be, an inverse relationship between CWEQ II score and nurses years of work experience was revealed in the data analysis. One would assume the relationship would be in the positive direction, showing more experienced nurses with higher scores for workplace empowerment, but we found the opposite association. Because no association was found between the proportion of nurses certificated on a unit and the experience level, there appears to be an element of experience that underlies the perception of workplace empowerment independent of certification status. Some plausible explanations for this finding may be due to the sample population (which included only staff nurses), a factor unique to the ICU environment, the degree of education, or perhaps a function of the type of institution (academic vs community facility). Further analysis of this important finding is required in order to determine the perception of workplace empowerment among the most experienced, and many times, most valued nurses. The lack of an appreciable association between nursing specialty certification and nursing-sensitive outcomes in the second portion of our framework was disappointing but not altogether unexpected. The absence of a definitive link between certification and patient outcomes has been reported in other studies that examined outcomes of medication errors, 25 postoperative complications, 27 falls, 28 rates of hospital-acquired pneumonia, 28 and prevalence of pressure ulcers. 28 Whether or not an increase in the sample size may have be enough to strengthen the relationship to reach a level of significance is unclear. However, the finding of an association between rehabilitation nurses certification as a CRRN and a decreased LOS 24 leads us to consider the possibility that the association between nursing specialty certification and nursing-sensitive outcomes may be strengthened when examined in relation to specific nursing practice environments. For example, in a medical ICU, the CCRN certification may be analyzed in association with nursing-sensitive outcomes specific to that population of patients rather than to outcomes that may be associated with patients in the a cardiothoracic or surgical ICU. In addition, the investigation of near misses, not actual adverse outcomes, may provide an overlooked association with the percentage of nurses certified on a unit. Furthermore, researchers doing qualitative and quantitative research on nursing specialty certification and patient outcomes may want to consider including positive outcomes for patients that may not be routinely collected. 38 Evaluation of positive outcomes, rather than adverse events such as those used in this study, may be a better way to examine the effects of nursing specialty certification. Measurement of positive outcomes in the ICU may consist of patient or family satisfaction or adequacy of nursing surveillance, early intervention practices, and satisfaction with pain control. Measurement of positive outcomes may be the key to capturing previously unrecognized nursing contributions, particularly given the relationship between certification and the influence of the workplace environment. Because nurses work in groups, the proportion of certified nurses in a work group may elevate the practice of the entire unit and therefore result in more positive outcomes for patients in all aspects of nursing practice. In order to keep pace with local and organizational policy initiatives that advocate specialty certification for nurses, additional research that explores the relationships between specialty certification and outcomes is imperative. Such research is especially important because the financial burden to achieve and maintain certification is usually borne by individual nurses. Few institutions reportedly defray the cost of certification and recertification, nor do they offer other incentives such as an increase in salary or bonus. 19,39,40 When certification can be translated into economic savings for the organization, much like the finding of the inverse relationship between LOS and CRRN certification, a business case for defraying the cost of certification can be justified. 496 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6

8 However, until evidence shows that improved patient outcomes are associated with certification, organizational support for certification will remain weak. Limitations In addition to the limitations of a nonexperimental, cross-sectional, retrospective design, this investigation included a limited sample size (of 25 intensive care units) and focused on a narrow geographic area. A prospective, longitudinal design would be necessary to demonstrate the strength of the association over time, as well as the direction of the relationship. In regards to the survey instrument, the type of specialty certification was not specified, thus, several types of certification were represented in this study, not only certifications for critical care nursing. Generalized, nonspecific data on nursing certification may not have the sensitivity to detect the specific ICU outcomes used for this analysis. Furthermore, we did not take into consideration whether or not nurses reported their initial certification or a recertification. Nurses who have gone through the recertification process may practice differently because recertification demonstrates nurses intrinsic value placed on certification, which may have ramifications for how nursing is practiced. Finally, because this study is a secondary analysis, the ability to modify existing variables was confined to those data that were collected. Conclusion This research is an important first step in attempting to understand the association between nursing certification and patient outcomes. In categorizing nursing certification not as a structural variable but as a process variable, the importance of workplace empowerment at the unit level emerged as a potential strategy for nurse managers and nurse administrators to increase certification rates in their units. Although there is little empiric evidence to link specialty certification with patients outcomes, selection of outcomes congruent with the particular nursing specialty certification and type of nursing care environment may be an approach to advance nursing science in this area and continue to validate nurses critical contributions to high-quality patient care. ACKNOWLEDGMENT A special thank you to Christine B. Feak, PhD, University of Michigan, for her invaluable assistance with manuscript preparation, review, and critique. FINANCIAL DISCLOSURES This study was funded by the Blue Cross Blue Shield of Michigan Foundation. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit and click Respond to This Article in either the full-text or PDF view of the article. SEE ALSO For more about certification, visit the American Journal of Critical Care Web site, and read the article by Fitzpatrick et al, Certification, Empowerment, and Intent to Leave Current Position and the Profession Among Critical Care Nurses (May 2010). REFERENCES 1. A position statement on the value of nursing specialty certification. American Board of Nursing Specialties. March 5, Accessed August 4, Your Guide to Certification. In: 2007 Career Guide. Am J Nurs. 2007: Guide to nursing certification organizations: specialty certification organizations Dimens Crit Care Nurs. 2008; 27(4): Rappl LM, Fleck C, Hecker D, Wright KD, Fredericks C, Mrdjenovich D. Wound care organizations, programs, and certifications: an overview. Ostomy Wound Manage. 2007; 53(11): Schoon CG, Smith IL. The Licensure and Certification Mission. New York, NY: Professional Examination Service; Institute for Credentialing Excellence, /tabid/54/default.aspx. Accessed August 10, National Commission for Certifying Agencies Accredited Certification Programs, June /AccreditedCertificationPrograms/tabid/120/Default.aspx. Accessed August 10, American Board of Nursing Specialties, Accessed August 4, AACN Position Statement. Certification and Regulation of Advanced Practice Nurses. American Association of the Colleges of Nursing /Publications/positions/cerreg.htm. Accessed August 4, American Board of Nursing Specialties Accredited Certification Programs /accreditation-exams.html. Accessed August 20, Manojlovich M, Antonakos CL, Ronis D. Intensive care units, communication between nurses and physicians, and patients outcomes. Am J Crit Care. 2009;18: Laschinger HKS. A theoretical approach to studying work empowerment in nursing: a review of studies testing Kanter s theory or structural power in organizations. Nurs Admin Q. 1996;20(2): Manojlovich M, DeCicco B. Healthy work environments, nurse-physician communication, and patients outcomes: making the link. Am J Crit Care. 2007;16(6): Laschinger H, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: expanding Kanter s model. J Nurs Admin. 2001;31(5): Patrick A, Laschinger HK. The effect of structural empowerment and perceived organizational support on middle level nurse managers role satisfaction. J Nurs Manage. 2006;14(1): Armstrong K, Laschinger H, Wong C. Workplace empowerment and magnet hosptial characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1): Piazza IM, Donahue M, Dykes P, Griffin MQ, Fitzpatrick JJ. Differences in perceptions of empowerment among nationally certified and noncertified nurses. J Nurs Admin. 2006;36(5): Cary AH. Certified registered nurses: results of the study of the certified workforce. Am J Nurs. 2001;101(1 part 1): Specialty Nursing Certification: Nurses Perceptions, Values and Behaviors. American Board of Nursing Specialties AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No

9 _12_12_06.pdf. Accessed August 4, Zulkowski K, Ayello EA, Wexler S. Certification and education: do they affect pressure ulcer knowledge in nursing? Adv Skin Wound Care. 2007;20(1): Redd ML, Alexander JW. Does certification mean better performance? Nurs Manage. 1997;28(2): Nursing Certification Bibliography. American Board of Nursing Specialties Accessed August 4, Wade C. Perceived effects of specialty nurse certification: a review of the literature. AORN J. 2009;89(1): Nelson A, Powell-Cope G, Palacios P, et al. Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehab Nurs. 2007;32(5): Bulla SA. The Relationship Between Nursing Specialty Certification and Medication Administration Errors and Incident Reporting [unpublished dissertation]. Fairfax, VA: George Mason University; Frank-Stromborg M, Ward S, Hughes L, et al. Does certification status of oncology nurses make a difference in patient outcomes? Oncol Nurs Forum. 2002;29(4): Newhouse RP, Johantgen M, Pronovost PJ, Johnson E. Perioperative nurses and patient outcomes: mortality, complications, and length of stay. AORN J. 2005;81(3): , , Redekopp MA. Relationships of Professional Nurse Characteristics and Nurse Staffing to Adverse Patient Outcomes [unpublished dissertation]. Milwaukee: University of Wisconsin; Kendall-Gallagher D, Blegen MA. Competence and certification of registered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18(2): Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83(4): Kanter RM. Men and Women of the Corporation. 2nd ed. New York, NY: Basic Books; Pringle D, Doran DM. Patient outcomes as an accountability. In: Doran DM, ed. Nursing-Sensitive Outcomes: State of the Science. Sudbury, MA: Jones and Bartlett Publishers; 2003: National Quality Forum. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington DC: National Quality Forum; Scoring of Nursing Work Empowerment Scales. Accessed August 4, Laschinger H, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics. J Nurs Admin. 2003;33(7/8): Dillman DA. Mail and Internet Surveys: The Tailored Design Method. 2nd ed. New York, NY: John Wiley & Sons, Inc; Laschinger H, Havens DS. Staff nurse work empowerment and perceived control over nursing practice, conditions for work effectiveness. J Nurs Admin. 1996;26(9): Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nursepatient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Admin. 2004;34(7-8): Safeguarding the patient and the profession: the value of critical care nurse certification. AACN Certification Corporation /certwhitepaper.pdf. Accessed August 4, Woods DK. Realizing your marketing influence, Part 3: Professional certification as a marketing tool. J Nurs Admin. 2002;32(7/8): To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. 498 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6

10 CE Test Test ID A : Nursing Specialty Certif ication and Nursing-Sensitive Patient Outcomes in the Intensive Care Unit Learning objectives: 1. Understand the association between intensive care units with a higher proportion of certified nurses and perceptions of the workplace empowerment. 2. Describe pertinent research examining the relationship between nursing specialty certification and patient outcomes. 3. Recognize that fostering an empowering workplace environment may enhance the rate of nursing specialty certification. 1. Which of the following nurse-sensitive patient outcome data were included in this study? a. Surgical site infections b. Ventilator-associated pneumonia c. Medication administration errors d. Catheter-associated urinary tract infections 2. Unlike licensure or certif ication, accreditation is targeted at which of the following: a. The individual level c. The organizational level b. Credentialed providers d. Licensed nurses 3. Which is a contextual factor of workplace empowerment? a. Confidence c. Self-esteem b. Opportunity d. Competence 4. Which of the following models of quality care was used as a theoretical framework for this study? a. The Institute for Healthcare Improvement methodology b. The Chronic Care model c. Langley s model for improvement d. The Donabedian structure-process-outcomes model 5. Which of the following groups comprised the study s sample population? a. Nurse managers c. Nursing supervisors b. Staff nurses d. Advanced practice nurses 6. Which of the following instruments was used to measure workplace empowerment? a. Conditions for Work Effectiveness Questionnaire-II b. Perception of Empowerment Instrument c. Psychological Empowerment Instrument d. Yeatts and Cready Dimensions of Empowerment Measure 7. Which of the following is correct about survey responses from each unit? a. The mean rate of specialty certification was 17%. b. The mean years of nursing experience was 3 years. c. The mean baccalaureate level of educational preparation was 25%. d. The mean response rate from each unit was a mean of 37%. 8. Results of the study demonstrated a strong, positive and statistically signif icant relationship between nurses perceptions of workplace empowerment and which of the following? a. The proportion of nurses with specialty certification on a unit b. The rate of adverse patient outcomes c. Certification and recertification rates d. Nursing-sensitive patient outcomes 9. What emerged in this study as a potential strategy for nurse leaders to increase certif ication rates in their units? a. Role modeling c. Workplace empowerment b. Clinical ladders d. Magnet recognition 10. Which of the following differentiates certif ication from licensure? a. Certification gives permission to practice. b. Certification is a legal requirement. c. Certification is awarded through state boards of nursing. d. Certification is voluntary. 11. Which of the following research studies found a statistically signif icant inverse relationship between specialty certif ication and length of stay? a. Relationships of Professional Nurse Characteristics and Nurse Staffing to Adverse Patient Outcomes b. Does Certification Status of Oncology Nurses Make a Difference in Patient Outcomes? c. Perioperative Nurses and Patient Outcomes Mortality, Complications and Length of Stay d. Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings 12. The research study, Competence and Certif ication of Registered Nurses and Safety of Patients in Intensive Care Units, found a statistically signif icant inverse relationship between the percentage of certif ied nurses on a unit and what outcome measure? a. Medication administration errors b. Bloodstream infections c. Falls d. Central catheter infections Test ID: A Contact hours: 1.0 Form expires: November 1, Test Answers: Mark only one box for your answer to each question. You may photocopy this form. 1. a 2. a 3. a 4. a 5. a 6. a Fee: AACN members, $0; nonmembers, $10 Passing score: 9 Correct (75%) Synergy CERP: Category A Test writer: Denise Drummond Hayes, RN, MSN, CRNP Program evaluation Name Member # Yes No Objective 1 was met Address Objective 2 was met Objective 3 was met City State ZIP Content was relevant to my Country Phone address For faster processing, take nursing practice this CE test online at My expectations were met RN License #1 State ( CE This method of CE is effective RN License #2 State Articles in This Issue ) or for this content mail this entire page to: The level of difficulty of this test was: Payment by: Visa M/C AMEX Check easy medium difficult AACN, 101 Columbia, To complete this program, Card # Expiration Date Aliso Viejo, CA it took me hours/minutes. Signature The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure. 7. a 8. a 9. a 10. a 11. a 12. a

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