CHAPTER 1: THE CERTIFICATION IMPETUS

A. What is Certification?

Nurse certification is the formal process by which a certifying agency, such as the American Nurses Credentialing Center (ANCC) validates a nurse's knowledge, skills, and abilities in a specialty area of practice. There are two types of certification: generalists' level or advanced practice level. Each requires different eligibility. Certification is reserved for those nurses who have met requirements for clinical or functional practice in a specialized field (ANCC website: www.nursecredentialing.org/cert/FAQ.html).

ANCC certification exams have demonstrated sound psychometric properties. Certification is:

• recognized by all state boards of nursing, as well as the U.S. military, and
• accredited by two national organizations: The American Board of Nursing Specialties (ABNS) and the National Commission for Certifying Agencies (NCCA) (ANCC Staff Development Resources: Available at www.nursecredentialing.org/staffdevelopment/pub.html).

B. Why certify in gerontological nursing?

Adults age 65 and older utilize 48% of the nation's total health care resources and represent approximately 38% of all admissions to hospitals (DeFrances & Hall, 2007; (Mezey, Quinlan, Fairchild, & Vezina, 2006). More than 13.2 million persons aged 65 and older in 2005 were discharged from short stay hospitals; this represents a rate of 3,596 for every 10,000 older patients which is over three times the comparable rate for patients of all ages (U.S. Administration on Aging, 2007). The aging trend will continue, with sustained and profound implications for nursing practice.

Many hospitalized older adults have multiple co-existing chronic health problems (U.S. Administration on Aging, 2007) and a higher acuity level than their younger counterparts, requiring advanced nursing knowledge. To provide the best care possible to older adult patients, nurses should be educated and certified in gerontological nursing care. However, less than one percent of U.S. nurses are certified in gerontological nursing (Stierle et al, 2006).

Some nurses are certified in another nursing specialty although older adults make up the majority of patients in many nursing specialties. In 2005, the American Nurses Association issued, "Recognition of a Nursing Specialty, Approval of a Specialty Nursing Scope of Practice Statement and Acknowledgement of Specialty Nursing Standards of Practice," that directs specialty groups to address care issues related to older adults and, where applicable, identify ". . .that older adults represent either the primary or predominant population served, or a unique population served by the specialty." (Mezey, Bickford, Schumann, Mariano, Handberg, & Sutermaster, 2007). Many hospitals recognize that many of their nurses should be encouraged to have dual certification to meet the specialty needs of their older adult patients (Stierle et al, 2006).

C. The Value of Certification

1. The Value of Certification to Nurses

There are a number of compelling reasons for nurses to pursue gerontological nurse certification.
Nurses perceive that certification provides many intrinsic rewards such as:

• Enhances feelings of personal accomplishment
• Provides personal satisfaction
• Enhances professional credibility
• References: American Board of Nursing Specialties, 2006; Sechrist & Berline, 2006.

Nurses believe that certification validates specialized knowledge, indicates professional growth, and enhances professional credibility ((American Board of Nursing Specialties, 2006; Gaberson, Schroeter, Killen, & Valentine, 2003; Sechrist & Berline, 2006). Certified nurses have reported increased access to job-related power and better professional opportunities in their workplace. The recognition of nurses' knowledge and expertise in the specialty area is associated with feelings of empowerment (Piazza, Donahue, Dykes, Griffin, & Fitzpatrick, 2006). Adding a geriatrics certification to an existing specialty certification can also broaden professional opportunities (Stierle et al, 2006). In some hospitals certification my result in higher salaries and benefits (Bacon, 2007).

2. The Value of Certification to Nurse Managers and Administrators

Management encouragement of certification demonstrates support for nurse advancement by reimbursing the exam fees and continuing education as well as listing certification credentials on a nametag or business card (American Board of Nursing Specialties, 2006). This support for education and certification have been positively associated with retention and reduced turnover rates as well as Health systems that encourage certification have described this as an effective tool for nurse recruitment (Piazza, Donahue, Dykes, Griffin, & Fitzpatrick, 2006; Woods, 2002).

A nurse manager at a NICHE hospital program stated:

"Certification provides nurses with a strong foundation to practice in geriatric nursing. This knowledge base allows nurses to provide valuable comprehensive input into every aspect of the patient's plan of care. Our certified nurses are valuable resources to everyone on the healthcare team."

Nurse Managers value certification. Nurse Managers have expressed a preference to hiring certified nurses because certified nurses have documented knowledge and experience in their specialty (Stromberg et al, 2005). By undertaking the certification process, certified nurses have shown a commitment to their profession and to providing a higher quality of care to their patients (Manojlovich, 2005).

At NICHE we view the Geriatric Resource Nurse (GRN) Model as foundational to implementing system-wide improvement in the care of older adult patients. (See Niche_models.pdf). The goal of the GRN model is improving the geriatric knowledge and expertise of the bedside nurse. The GRN model prepares staff nurses as a clinical resource person on geriatric issues to other nurses on their unit. GRNs when compared to staff nurses demonstrate evidenced-based gerontological nursing care practice (Mezey, Quinlan, Fairchild, & Vezina, 2006).

Since GRNs are expected to have a higher level of knowledge and experience in caring for older adults, achieving national certification can be the external benchmark of the hospital's effectiveness in implementing the GRN model.

When a hospital expands their NICHE program to specialty units the nurses may already be certified in another area, however, the focus on meeting the specific needs of older adults within that specialty may often result in nurses receiving their second certification in geriatric nursing. Nurses with dual certification can improve a hospital's capacity to respond to unit-based (e.g., reducing restraint use in critical care units) or community needs (e.g., developing health care promotion programs for older adults), to apply for grant-funding opportunities, and to meet requirements of the Joint Commission on Accreditation of Healthcare Organizations (Stierle et al, 2006).

3. The Value of Certification to Patients

Patients and their families expect knowledgeable caregivers at the bedside. Certification verifies nurses are highly skilled and possess expert knowledge in providing excellence in gerontological nursing care. Nurse supervisors have rated certified nurses, when compared to non-certified nurses, with higher performance scores for education/collaboration, care planning, and evaluation (Redd & Alexander, 1997). Certified nurses have also demonstrated evidenced-based gerontological nursing care practices (Mezey, Quinlan, Fairchild, & Vezina, 2006) such as higher accuracy in pressure ulcer staging (Hart, Bergquist, Gajewski, & Dunton, 2006).

D. Certification and Magnet

The Magnet Recognition Program of the American Nurses Credentialing Center (ANCC; See: www.nursecredentialing.org/magnet/index.html) designates hospitals as Magnet that demonstrate that nursing staff:

• Delivers excellent patient outcomes
• Exhibits a high level of job satisfaction
• Has a low nurse turnover rate
• Demonstrates appropriate grievance resolution

In order for a hospital to achieve Magnet status, it must exhibit professional development by promoting certification in clinical practice and administrative nursing roles. Certification therefore enhances a hospital's potential for Magnet status.

A survey of 52 Magnet hospitals found that the majority reimbursed nurses for the cost of the exam registration and display their certification letters on ID badges while several provided bonuses to nurses for certification (Weeks, Ross & Roberts, 2006). When a hospital supports nurses in becoming certified, this is evidence that hospital leadership:

• Values staff nurses
• Includes nurses in creating evidence-based nursing practice
• Rewards them for advancing in nursing practice (www.nursingadvocacy.org/faq/magnet.html) Nursing

E. Certification and Measures: Process and Outcome

Certified gerontological nurses utilize gerontological competencies as they implement the nursing process with their patients. Certified nurses:

• Assess, manage and deliver healthcare that meets the needs of older adults
• Evaluate the effectiveness of their care
• Identify strengths of their patients
• Maximize independence
• Involve patients and family members (www.nursecredentialing.org/cert/eligibility/geroADN.html)

F. Certification: Support of Mission and Vision

The certification process prepares nurses to practice congruent with a hospital's mission, vision and values of providing excellence in nursing care. Additionally, by meeting national standards, certification empowers nurses as professionals congruent with an organizational goal of promoting a positive work experience for nurses.

One Chief Nursing Executive volunteered very strong feelings about nursing certification:

"Our organization is dedicated to holding nursing in the highest regard, while fostering individual development in a professional practice environment. One of the strategies used to encourage individual development is supporting nurses who wish to become certified in a professional organization or discipline. Nursing leadership believes that certification for nurses enhance our clinical practice with up-to-date knowledge and skills learned through the certification journey. When our nurses become certified we also take time to recognize and celebrate their accomplishments and acknowledge their commitment to nursing excellence.

Our nursing team is committed to providing quality, relationship-centered care through shared decision-making and evidence-based practice. Leadership, expertise, pride, respect and compassion are principles that combine to ensure our patients receive the best nursing care."