CHAPTER 2. LAUNCHING A CERTIFICATION INITIATIVE

A. Assess Commitment and Need

Identifying the knowledge and skill levels of nursing staff, as well as their attitudes in regard to care of older adults can take several forms. Common approaches are described below.

• 1. Acknowledging that many nurses have not had preparation in gerontological nursing is an important first step. (The average age of the nurse today is 46.8 years (HRSA, 2007), and consequently the majority did not have gerontological nursing content in their basic nursing education (Berman et al, 2005). Additionally, there is a need to recognize the common misperception that simply working with older adults, without focused educational preparation, is associated with specialized gerontologic skill and knowledge.
• 2. A review of quality indicators and performance improvement measures can provide the basis for educational needs. The nursing sensitive quality indicators of pain, falls, pressure ulcers, restraint use and patient satisfaction are all relevant to care of the older adult and are appropriate to identify areas for clinical improvement and education. Trending hospital data by age group will likely demonstrate that those patients with potentially preventable complications such as pressure ulcers, nosocomial infections and deconditioning (functional decline leading to post-discharge rehabilitation) are most likely older patients.
• 3. Staff and Professional Development programs can administer educational needs assessments and identify from continuing education program evaluations geriatric care education needs. Incorporating hospital based competencies in care of older adults (www.hartfordign.org/resources/education/competencies.pdf) within annual competency reviews and performance evaluations can promote accountability and responsibility in applying evidence-based practice gerontological nursing. These competencies can be used in conjunction with the BSN competencies (www.aacn.nche.edu/Education/gercomp.htm) and the curriculum map developed by the American Association of Colleges of Nursing and Hartford Institute for Geriatric Nursing to facilitate the development of educational needs assessments (see www.hartfordign.org/resources/education/curriculumMap.doc).
• 4. Another method of quantifying and describing the need for gerontological knowledge and skills is through the Geriatric Institutional Assessment Profile (GIAP – see www.nicheprogram.org/benchmarking) from The NYU Hartford Institute NICHE Benchmarking Service. GIAP is used as a measure for the overall quality of care provided to older adults and serves as a benchmarking tool to assist hospitals in identifying gaps. These gaps are in knowledge about geriatric care, attitudes and perceptions that influence how staff works with older patients, specific practice issues and concerns, and organizational attributes of the hospital relevant to geriatric care (www.nicheprogram.org/benchmarking).
• 5. Reports of external regulating bodies (i.e. JCAHO, Magnet) can yield information about nurses' needs for education by identifying areas of improvement in clinical practice.
• 6. Comparing the number of nurses certified in gerontological nursing to other certifications in the organization is important baseline information, given that the majority of patients are typically older adults.
• 7. Providing a support structure for nurses preparing for the gerontological nursing certification exam through classes and cohorts that prepare together can surface additional nurses interested in obtaining certification.

The methods noted above can be combined to determine the need for developing a certification exam preparation course and to increase the number of certified gerontological nurses within healthcare organizations.

B. Secure Support

As you embark upon a gerontological nurse certification campaign, it is critical to create a sense of urgency and need. Mathy Mezey, EdD, RN, FAAN, director of the Hartford Institute for Geriatric Nursing at NYU College of Nursing, captures a sense of urgency best with this statement: "The population of older Americans is exploding. Geriatric patients are not one sub-group of patients but rather the core business of health systems." (Quote from: www.consultgerirn.org/certification)

Continue to build your case for certification with these comments from The American Nurses Credentialing Center website:

• "Certification protects the public by enabling anyone to identify competent people more readily."
• "Simultaneously it aids the profession by encouraging and recognizing professional achievement."
• "Certification also recognizes specialization, enhances professionalism and, in some cases, serves as a criterion for financial reimbursement."
• "It may also foster an enlarged role within the employment setting. Because certification of nursing practice signifies attainment of specific criteria and knowledge, skills, and abilities in a specific specialty field, certified nurses comprise a minority of the professional nurse population."

C. Obtain/Present Data to Administrative Team

Gather statistics on each adult patient care unit (collaborate with Decision Support or Finances Department) such as:

• Percentage of patients 65 plus years of age
• Outcomes by age groups by age groups: 18-64 versus 65 and older (Or 65-74, 75-84, 85 and older)
  • 1. Length of stay
  • 2. Re-admissions within 30 days
  • 3. Percentage with complications such as nosocomial pressure ulcers, infections, fall-related injuries

Also find out unique facts about your state or region such as:

• Number of centenarians in your state
• Rank of your state/county in percentage of older adults
• Expected trends in aging population.

Schedule a brief (10-15 minutes) presentation with your organization's administration, chief nurse executive, nursing leaders, and unit directors.

Use this power point presentation example, inserting your organization's statistics: Attachment: Chapter2.C_Present_Data_To_Administrative_Team_Sanford_Example.ppt

As you present the information, personalize the information by asking each unit's director or manager to guess what percentage of their patient population is over 65 years old along with the answers to the unique clinical questions.

D. Gain Chief Nurse Executive/Officer support

Your chief nurse executive (CNE) or officer (CNO) can be a powerful partner in promoting certification. Ask for the CNE/CNO strong endorsement of certification efforts. Certification is a criteria and component for Magnet hospitals and is an important bench mark for consumers in validating clinical expertise. If your CNE/CNO is supportive that endorses the importance to patient care directors who may establish a goal to have a certain number or percentage of their staff certified.

E. Address Human Resource Issues

The major barriers identified by nurses for not seeking certification include: easy access to certification preparation, financial support for certification preparation and exam costs, and recognition following certification (Woods, 2002).

As an organization discuss the overall issue related to reimbursement when a nurse attends educational sessions to demonstrate competencies or certifications necessary to perform their job. Establish what type of support the health system will provide to encourage nurse certification, regardless of specialty and then decide what is the level of support for gerontological certification for nurses working in geriatric-specific (e.g., Acute Care for the Elderly), medical-surgical and specialty units with high number of older patients.

Then assess resources in your organization:

• Financial
• Seek Internal sources of funding: department level or hospital/community foundations, for example, explore funding from own hospital foundations or philanthropic community foundations and organizations
• External sources:
  • 1. Government, eg. HRSA Geriatric Nursing Education grants
    • HRSA Grant Opportunities: www.hrsa.gov/grants/
    • HRSA Forms: www.hrsa.gov/grants/forms.htm
  • 2. Regional/local Foundations
• If you decide to write a grant to support your program:
  • 1. Assemble a committee of nurse leaders and advanced practice nurses to provide clinical perspective and assist with grant writing.
  • 2. Identify who in your organization (Public Relations Department, Nursing Research) that can assist you in grant preparation.
  • 3. Consider focusing on an underserved population in your community, for example link your goals for training to "Healthy People 2010" (see www.healthypeople.gov/) or other government national/regional goals/programs.
  • 4. Include a convincing purpose, need and rationale for your program – Attachment: Chapter2.E_Grant_Purpose_Need_Rationale_BronsonExample.pdf
  • 5. Include an action plan for meeting project goals. Attachment: Chapter2.E_Grant_Action_Plan_BronsonExample.pdf
  • 6. Provide a detailed timeline with measurable goals and outcomes. Attachment: Chapter2.E_Grant_Timeline_Measures_BronsonExample.pdf
  • 7. Obtain letter of agreement to use NICHE resources as part of the grant. Attachment: Chapter2.E_Grant_Letter_of_Permission_to_NICHE_BronsonExample.pdf
  • 8. Obtain letters of endorsement from stakeholders in the community
• Faculty
  • Check the availability of in-house faculty
  • Are there potential external faculty? What are the costs for an honorarium or travel expenses?
• Space for classes
  • AV equipment
  • Computer access

Establish criteria for certification support – consider which of the following will be used to determine who will receive education and other forms of support for certification, such as:

• Performance
• Tenure
• Interest
• Career ladder

In some healthcare systems, certifications are viewed as a requirement for employment and thus are paid for by the organization. For example, at Bronson Methodist Hospital, gerontological certification is a term of their employment for nurses working on acute medical units so the unit covers the cost of the exam. Certifications not required for employment fall under the organizational certification benefit.

Develop specific guidelines and a form to operationalize these criteria. The following tools are examples from two NICHE Hospitals that have established certification programs:

• Reimbursement for Certification Exam Fee from the Nebraska Methodist Hospital Foundation Attachment: Chapter2.E_Reimbursement_Cert_Fee_NebraskaExample.pdf
• The Bronson Healthcare Group Certification Program Promissory Note Attachment: Chapter2.E_Promissory_Note_BronsonExample.pdf

Certification assistance policy forms (for example, Bronson Methodist Hospital in Kalamazoo, MI) may include language regarding:

• Statement of employee commitment: ex., One-year period of employment that begins on the date class/certification is completed.
• Nurse managers/director review and validation of certification application as a first step in applying for certification assistance.
• Completion of Application and Promissory Note (See Bronson Healthcare Group example described above). Approval of paperwork completed prior to taking certification exam.
• Request for Check must be completed and submitted to Education Services.
• Changes/withdrawals must be communicated to the Educational Department:
  • Submission of copy of certification to Education Services within 30 days of completion of exam.
  • Employee in process of repayment will be ineligible for further financial assistance until money is totally repaid.

F. Develop a Budget

Budget preparation includes cost of development and implementing a course and as well as providing incentives to participate in examination preparation. The budget should also include funds for post-examination recognition (see chapter IV).

• View a sample budget for Gerontological Nurse Certification Course - Attachment: Chapter2.F_Course_Budget_SanfordExample.pdf
• Encourage Nurse Managers to facilitate staff nurse membership in National Gerontological Nurse Association to qualify for reduced rate of certification test taking fees.

G. Develop a Plan to Address Logistics

Organize your activities in a plan and timeline. View all the pages of the following excel spreadsheet to get started:

• Chapter2.G_Activities_Plan.xls

Prepare a timeline of activities for each month

• See Attachment: Chapter2.G_Cert_Activities_Timeline.pdf

Month 1

• Obtain Administrative and supervisor approval and support
• Discuss certification vision with your supervisor and obtain buy-in
• Confirm clerical support to schedule rooms, register participants, copy papers
• Present PowerPoint to administration and nursing leaders

Month 2

• Marketing blitz
• Posters
• Fliers
• Unit newsletters
• Personal invitations, unit champions
• Promote at unit meetings

Month 3

• Informational and planning meeting for participants, confirm interest
• Determine minimum # participants necessary to hold class (i.e. 10, 20)
• Confirm curriculum and invite speakers

Month 4

• Schedule rooms
• Secure AV support, videoconferencing, video recording
• Order texts, 3-ring binders, paper supplies

Month 5

• Class 1 & 2
• Refreshment schedule, calling tree, group email

Month 6

• Class 3 & 4
• Send in applications to ANCC

Month 7

• Class 5 & 6

Month 8

• Class 7 & 8

Month 9

• Exam

Month 10

• Celebration
• Recognition events

H. Identify Nurse Champions

Provide information about the certification course and ask each director to personally ask three nurse champions or opinion leaders on their unit to take the course. Nurses are honored and flattered to be asked by their supervisor and often just need some encouragement. As you round on the units, promote the certification course, and personally ask three more nurses.

Most nurses have not taken an exam since their initial licensure exam and their biggest fear often is not passing. Encourage them that this course will provide information to help them successfully pass the exam. Let them know that the pass rate is quite high for the gerontological nurse exam, with an approximate 70% pass rate in 2006.

I. Publicize! : Posters, Newsletters, Unit Meetings

Place posters in the elevators, break rooms, locker areas. Provide a name and number for the nurse to contact for more information. Most units have monthly newsletters, use the poster information and contact number. Attend unit meetings and answer questions about the certification course. See Attachment: Chapter2.I_Gero_Cert_Course_NebraskaExample.pdf for an example of a professionally-developed brochure of a course open to nurses within and outside the Nebraska Methodist Hospital (Omaha, NE) health system.

J. Hold an Informational meeting

Email or contact interested participants of a noon brown bag informational meeting. This meeting is an excellent opportunity to encourage participants, allow for question/answer time, and provide more detailed information. If the day and time of the class is negotiable, gather a consensus of when they would like to take the class. See Attachment: Chapter2.J_Informational_Meeting_SanfordExample.pdf for a sample outline of an informational meeting. You might consider having a letter of agreement (see example – Attachment: Chapter2.J_Letter_of_Agreement_SanfordExample.pdf) which encourages accountability and commitment from the participant to complete the entire course and take the exam. At the first class, ask the participants to sign and turn in the Letter of Agreement.