Overview of the State
of the Research:
Individual Credentialing
Meg Johantgen, PhD, RN
Associate Professor, Organizational Systems and Adult Health University of Maryland School of Nursing, Baltimore
Focus of this review:
•
Limited to U.S.
•
Nursing – post-entry level and post MSN/DNP
•
Not including advanced practice roles of nurse practitioner (NP),
clinical nurse specialist (CNS), nurse-anesthetists (CRNA), or
midwife (CNM)
Individual Certification in Nursing
midwife (CNM)
• Certification is not voluntary for these 4 advanced practice roles – systematic review (Newhouse et al., 2011)
•
Any certifying organization, for example:
• American Nurses Credentialing Center • Competency and Credentialing Institute
• American Association of Critical Care Nurses Certification Corporation • Oncology Nursing Certification Corporation
•
NOT nurse-reported perceptions of benefits and outcomes
•
Common sources and outcomes:
• Administrative data – outcomes (e.g., infection, falls, medication errors, mortality, failure to rescue)
• Administrative data – nurse (e.g., education and certification) • Primary data collection (e.g., survey for specialty certification)
Types of Outcomes
• Primary data collection (e.g., survey for specialty certification)
Nurse specialty certification, inpatient mortality, and failure to rescue
(Kendall-Gallagher et al., 2011)
•
Sample:
• Surgical patients from 652 hospitals in FL, CA, PA, NJ • Staff nurse sample (N=28,017) from Board of Nursing lists
•
Design:
Patient Outcome Study Example 1
•
Design:
• Secondary analysis – data aggregated to hospital-level • Certification measured from individual nurses
•
Findings:
• On average at the hospital level, % BS certified 38.3% (range 0-100) • % BS education and % BS certified (vs. AD/diploma) significantly
Limitations cited by Kendall Gallagher et al. (2011)
•
Unknown types of staff nurse specialty certification, making it
difficult to consider the relation of specific clinical knowledge to
surgical morbidity and mortality
•
Moderate nurse survey response with potential response bias
Study Example 1 Limitations
•
Administrative discharge data may not be coded accurately or fully
represent illness severity to risk adjust patient outcomes
•
Logistic models did not control for other hospital characteristics
that may influence patient outcomes
Nursing specialty certification and nursing-sensitive patient outcomes
in the intensive care unit (Krapohl et al., 2010)
•
Sample:
• 25 ICUs in Michigan
• ICU staff nurse survey (N=450 useable surveys)
•
Design:
Patient Outcome Study Example 2
•
Design:
• Survey responses aggregated to unit level and linked to unit level outcomes
• Certification measured as “specialty” Yes/No
•
Findings:
• On average, 17% of nurses were certified (range 4-38)
• No significant effect of certification on rate of central line catheter infections, ventilator-associated pneumonia, or pressure ulcers
Limitations cited by Krapohl et al. (2010):
•
Sample of 25 intensive care units and focused on a narrow
geographic area
•
Moderate response to nurse survey may indicate non-response
bias (i.e., those who are not certified may not answer)
Study Example 2 Limitations
•
Varied types of specialty certification were represented (not only
certifications for critical care nursing)
•
Administrative data may have coding errors that influence
outcomes, and there was no ability to collect other variables
Outcomes Study (significance)
Falls Kendall-Gallagher 2009 (+); Lange 2009 (+) Pressure ulcer development Kendall-Gallagher 2009 (-); Krapohl 2010 (-) Medication errors Kendall-Gallagher 2009 (-)
Blood stream infection Frank-Stromborg 2002 (-)
Central venous catheter infection Kendall-Gallagher 2009 (-); Krapohl 2010 (-) Urinary tract infection Kendall-Gallagher 2009 (-)
Summary of Outcomes in Relation to
Certification
Urinary tract infection Kendall-Gallagher 2009 (-) Ventilator-associated pneumonia Krapohl 2010 (-)
Other infections Frank-Stromborg 2002 (-)
Complications Newhouse 2005 (-)
Mortality Newhouse 2005 (-); Kendall-Gallagher 2011 (+) Failure to rescue Kendall-Gallaher 2011 (+)
Length of stay Nelson 2007 (+)
•
Correlational studies (associations are not causal)
•
Difficult to isolate independent effect of nurse on patient outcomes
• Care is delivered by a team
• Data must be aggregated to unit or hospital level
•
Outcome measures rely on administrative data which may have
Summary of Limitations
•
Outcome measures rely on administrative data which may have
errors in coding, unclear attribution to a single unit, and may not
be risk adjusted
•
Influence of confounding variables not consistently examined
•
Building support for research
• Individual nurse and organizational motivations to seek and promote certification vary
• Lack of data systems to track dates and types of certification and recertification
•
Isolating the effect of certification
Research Challenges
• Team care
• Confounding variables
•
Measuring outcomes specific to certification
• Inpatient • Outpatient
Coleman, E. A., Coon, S. K., Lockhart, K., Kennedy, R. L., Montgomery, R., Copeland, N., McNatt, P., Savell, S., & Stewart, C. (2009). Effect of
certification in oncology nursing on nursing-sensitive outcomes. Clinical
Journal of Oncology Nursing, 13(2), 165-172.
Frank-Stromborg, M., Ward, S., Hughes, L., Brown, K., Coleman, A., Grindel, C. G., & Murphy, C. (2002). Does certification status of oncology nurses make a difference in patient outcomes? Oncology Nursing Forum, 29(4), 665-672.
References
Kendall-Gallagher, D., Aiken, L. H., Sloane, D. M., & Cimiotti, J. P. (2011).
Nurse specialty certification, inpatient mortality, and failure to rescue. Journal
of Nursing Scholarship, 43(2), 188–194.
Kendall-Gallagher, D., & Blegen, M..A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American
Lange, J., Wallace, M., Gerard, S., Lovanio, K., Fausty, N., & Rychlewicz, S. (2009). Effect of an acute care geriatric educational program on fall rates and nurse work satisfaction. Journal of Continuing Education in Nursing, 40(8), 371-379.
Nelson, A., Powell-Cope, G., Palacios, P., Luther, S. L., Black, T., Hillman, T., Christiansen, B., Nathenson, P., & Gross, J. C. (2007). Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing,
32(5), 179-202.
References continued
32(5), 179-202.
Newhouse, R. P., Johantgen, M., Pronovost, P. J., & Johnson, E. (2005). Perioperative nurses and patient outcomes—Mortality, complications, and length of stay. AORN Journal, 81(3), 508-509, 513-522, 525-528.
Newhouse, R. P., Stanik-Hutt, J., White, K.M., Johantgen, M., Bass, E.B., Zangaro, G., Wilson, R. F., Fountain, L., Steinwachs, D. M., Heindel L., & Weiner, J. P. (2011). Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economic$, 29(5), 230-250.