Best Practices in Creating a Culture of Certificationdownloads.lww.com/wolterskluwer_vitalstream_com/... · practices in creating a culture of certification (Table 2). 2010 Certification

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Best Practices in Creating a Culture of Certification

AACN Advanced Critical CareVolume 22, Number 1, pp.33–49

© 2011, AACN

Rhonda K. Fleischman, RN, MSN, CNS, CCRN-CMC

Laura Meyer, RN, MS

Christine Watson, RN, BSN, CCRN

Value of Certified Practice: A ReviewCertification is the criterion standard of profes-sional practice, distinguishing excellence in nurs-ing care, mastery of knowledge, skills, andabilities beyond the scope of professional licen-sure. It is the validation of an individual nurse’squalifications for practice in a defined area.1 Thebody of literature relating certified practice to out-comes for patients, systems, and nursing is grow-ing. The American Nurses Credentialing Centeridentifies certification as a means toward theadvancement of nursing professionalism, higherstandards of care, and better patient outcomes.The American Nurses Credentialing Center fur-ther cites 8 organizational and professional rea-sons for supporting nurse certification (Table 1).2,3

Evidence from studies of the effects of certifi-cation on nurses identifies 3 key findings: an

Certification is the criterion standard of profes-sional practice, distinguishing excellence innursing care, mastery of knowledge, skills,and abilities beyond the scope of professionallicensure. It is the validation of an individualnurse’s qualifications for practice in a definedarea. Becoming certified is a personal and pro-fessional commitment that demonstrates thevalue that the individual nurse places on higherstandards of practice and lifelong learning. TheAmerican Association of Critical-Care Nurses(AACN) Beacon Award for Excellence, MagnetRecognition Program, and Malcolm BaldrigeNational Quality Award all recognize certifica-tion as a key component of nursing excellence

in specialty practice. Both the general public andnurse professionals increasingly recognize theneed for practice on the basis of evidence to pro-vide safe, quality patient care. In today’s rapidlychanging and complex health care delivery sys-tem, certification is becoming the standard bywhich bedside practice and the impact of nurs-ing care on patient outcomes are measured.This article will provide a review of current bestpractices in creating a culture of certification,including the journey of 3 hospitals selected asthe 2010 Best Practice Roundtable presentationsat the AACN National Teaching Institute.Keywords: best practice, certification, certifiedpractice, value of certification

ABSTRACT

Rhonda K. Fleischman is Cardiac Care Unit Clinical EducationSpecialist, Aultman Hospital, 2600 6th St SW, Canton, OH44710 ([email protected]).

Laura Meyer is Clinical Manager Critical Care, Portland VAMedical Center, Portland, Oregon.

Christine Watson is Pediatric Intensive Care Unit Clinical IVNurse—Education Track, Children’s Hospital of Philadelphia,Philadelphia, Pennsylvania.

DOI: 10.1097/NCI.0b013e3182062c4e

increased confidence in a nurse’s abilities, ear-lier intervention to prevent problems, and morenurse/physician collaboration.4 A review of theliterature and perceived effects of specialtynursing certification by Wade5 revealed that themajority of studies conducted in the past 2decades found certification to be positivelyassociated with nurses’ job satisfaction, a sense

Copyright © 2011 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.

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FLEISCHMAN ET AL AACN

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of empowerment, and a sense of collaboration.This review further demonstrated an associa-tion between certification and nurses’ percep-tion of patient satisfaction and patient reportsof satisfaction.5 Through autonomy over prac-tice and increased clinical expertise, certifica-tion provides nurses with the means to practicein a way that can improve patient outcomes.

In 2002, the American Association of Critical-Care Nurses (AACN) released a white paper,Safeguarding the Patient and the Profession: TheValue of Critical Care Nurse Certification, out-lining the benefits of specialty nursing certifica-tion for the public, employers, and nurses.6 Otherspecialty organizations have developed similarposition papers and reported studies related tocertified practice.7–9 The effects of certification onnurse-sensitive patient outcomes have been posi-tively identified in recent literature and practiceguidelines including the relationship between cer-tification, increased knowledge, and improvedpatient management.10–12

According to a Harris poll, consumer aware-ness that nurses can be certified is high, findingnurses to be the most recognizable certified pro-fessionals.13 Americans surveyed identified con-tinuing education for nurses caring for criticallyill patients to be very important and preferredhospitals that employ nurses with specialty cer-tification. This awareness has made it increas-ingly important to assure the public that nursesare competent in providing safe, quality care.13

Creating a Culture: Common ThemesMerriam-Webster defines culture as a set ofshared attitudes, values, goals, and practicesthat characterize an institution or an organiza-tion.14 A culture of certification promotes and

supports certified nursing practice. Severalthemes that identify effective strategies indeveloping a successful culture supportive ofcertified practice have emerged from the litera-ture. Common incentive strategies focus onfinancial support from employers, promotions,recognition, and peer support.15,16 A compila-tion of certification initiatives from across thecountry including best practice highlights fromNational Teaching Institute (NTI) certificationroundtable presentations is available on theAACN Web site.17 Five themes emerge fromthis valuable resource for units seeking bestpractices in creating a culture of certification(Table 2).

2010 Certification Best PracticesIn the fall of 2009, AACN posted a call forabstracts of best practice strategies in pro-moting and creating a culture of certification.The chosen abstracts were presented at the2010 NTI Certification Roundtable session inWashington, DC. These roundtable experiencesoffered NTI participants not only 3 professionalbest practice presentations but also the abilityto discuss certification. This approach pro-vided an opportunity for participants to learnnot only from presenters but also from nursesaround the country who are struggling withmany of the same barriers and experiences. Inaddition, innovative strategies in promotingcritical care specialty certification from aroundthe country were revealed.

The 3 best practice abstracts selected for the2010 NTI Certification Roundtable represent abroad range of both organizational and profes-sional perspectives in approaching and devel-oping successful strategies in creating a cultureof certification. Organizationally, the presen-tations discussed the experience of 2 differentadult critical care units. Aultman Hospital’scardiac care unit (CCU) and the medical-surgical


Table 1: Reasons for Supporting NurseCertificationa

Professional recognition

Personal recognition

Career progression

Professional opportunities and networking

Competency assessment

Licensure

Reimbursement

Increased salaryaAdapted with permission from Smolensky.3

Table 2: AACN Best Practice CertificationRoundtable Themes

Commitment to excellence

Supportive and encouraging environment

Setting a goal/goal-directed evaluations

Available educational resources

Celebration and rewarding excellence

Abbreviation: AACN, American Association of Critical-Care Nurses.17


VOLUME 22 • NUMBER 1 • JANUARY–MARCH 2011 BEST PRACTICES IN CREATING A CULTURE OF CERTIFICATION

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critical care unit of the Portland VeteransAdministration Medical Center (PVAMC)depict journeys through the professional lensof a clinical nurse specialist (CNS) and a nursemanager. In addition, The Children’s Hospitalof Philadelphia (CHOP) depicts a pediatricintensive care unit’s journey from the staffnurse perspective. As outlined in the individ-ual stories below, these best practices providecreative and well-rounded approaches to pro-mote certification.

Aultman Hospital Best PracticeBackgroundAultman Hospital is an 808-bed, Magnet- designated facility in Canton, Ohio, whosemission is to lead the community to improvehealth. In addition to operating 6 centers ofexcellence, Aultman is a teaching hospital fea-turing 5 residency programs and has a nursingeducation program, Aultman College of Nurs-ing and Health Sciences. For the fourth year in2010, Aultman was named one of the 100 tophospitals in the country by Thomson Reuters.In addition, Aultman is Stark County’s largestand “most preferred hospital for overall qualityand image” for the 14th consecutive year, asnamed by the National Research Corporation.18

Building the FoundationThe journey toward creating a culture of certi-fication throughout the cardiac division beganin 2001 with the creation of a cardiac curricu-lum based on 5 levels. Before the curriculum’sdevelopment, cardiac staff education wasoffered via a traditional approach with classesoffered as needed, but without formal struc-ture and minimal support toward certification.The purpose of the curriculum was to providestructured cardiovascular and critical careeducation to the staff using Patricia Benner’sNovice to Expert model as the framework andto encourage staff members to seek specialtycertification (Table 3).19 The cardiac curriculumcovers advanced knowledge—that is, beyondcritical care orientation and new staff educationrequirements.

Each level of the curriculum is designed tobuild on the previous level and introduce newcontent appropriate to the developmental level ofthe clinician. Curriculum content was identifiedusing current cardiovascular and critical careexamination blueprints, practice standards, andquality measures. The curriculum is reviewed

annually for needed revisions. Free continuingeducation credits are provided to participants,with a total of 80 education hours available forcompletion of the program. The first 3 levels ofthe program consist of 1-hour sessions with eachlevel providing 16 hours of education, whereasthe fourth level consists of a 32-hour certificationpreparation course (Table 4).

The heart of the curriculum lies in theapproximately 30 clinical instructors (CIs)who take ownership of development and pres-entation of each class. Instructors must bemaster’s-prepared or have specialty certifica-tion. The cardiac CIs are currently engaged inbedside practice. Instructors consist of cardiacadvanced practice nurses, cardiac sonogra-phers from the noninvasive heart laboratory,bedside nurses from the CCU, cardiovascularsurgical intensive care unit staff, invasive car-diac catheter laboratory staff, and cardiacrehabilitation unit staff (Figure 1). This groupmeets monthly as a formal shared decision-making committee. The Cardiac Staff Educa-tion Committee (CSEC) is responsible to reviewcurriculum content, current cardiovascular andcritical care literature, and evidence-based prac-tice standards. The committee also addressesinstructor and creative teaching strategy skilldevelopment. Peer review of class content andteaching strategies is conducted on a routinebasis. An annual “Instruct the Instructor” work-shop is presented by the committee’s chairs.

During the past 2 years, the CSEC hasworked to broaden the program’s frameworkto include the AACN Synergy Model forPatient Care. This model is based on the funda-mental tenet that patient characteristics drivenurse competencies (Table 5).20 When patientcharacteristics and nurse competencies are insynergy, optimal patient outcomes result.21

Instructors have incorporated relevant patientcharacteristics and nurse competencies fromthe Synergy Model into class content to stimu-late critical thinking.

The Cardiac Staff Education Program (CSEP)is designed to challenge bedside clinicians tocontinue to improve their practice. Through-out each class, clinicians learn new practiceskills or critical thinking skills they can apply.One key strategy has been to link education ateach program level to the bedside. The LinkingKnowledge to Practice initiative includes clini-cal practice expectations for each class. Theseexpectations reflect practice changes that canbe measured in clinical practice (Table 6).




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Clinicians are expected to apply these practicestandards in their daily practice. By linkingknowledge learned in the classroom to practice,correlations between knowledge and outcomescan be identified. In addition to discussing theselinking knowledge to practice expectations inthe classroom, teaching strategies include “callout” slides in PowerPoint presentations andpocket cards delineating clinical expectations.

Building Confidence: Creating UnitCulture “One Nurse at a Time”The CCU is a 56-bed unit with more than 110registered nurses (RNs), advanced practicenurses, and support staff. The staff of this 3-time Beacon Award–achieving unit providecare to medical cardiac patients who require

both intensive care and step-down levels of care.Although the CSEP serves as the educationalstructure for the CCU, building confidence “onenurse at a time” has been the approach to cre-ate the unit’s certification culture. A personaleducation plan is developed by the unit-basedCNS and individual nurse. This plan isreviewed annually and addresses how thenurse prefers to complete the 4-level cardiaccurriculum. New RN hires are oriented to thecurriculum at the beginning of the orientationprocess.

A common barrier identified by staff nursesto becoming certified is a fear of failure. Build-ing confidence through a variety of initiativeshas been a key strategy to increasing the num-ber of certified staff. Upon initiating the level 4


Table 3: Aultman Heart Center Novice to Expert Cardiac Education Programa

Level 1—beginning practitioner

Designed for new heart center employees

Key to building a solid cardiovascular foundation

Expand on cardiovascular content introduced in hospital critical care course

Level 2—advanced beginner

Class content designed to increase knowledge base after clinical orientation to assigned cardiac unit

Learning opportunities support confidence as clinical skills are being developed

Level 3—skilled practitioner

Education focused on more advanced concepts enabling the clinicians to continue to expand their depth of knowledge of the cardiac patient

Classes designed to encourage critical thinking and challenge day-to-day concepts with more depth and detail

Level 4—proficient practitioner

Clinician demonstrates high level of proficiency in care and is able to provide guidance and direction to other staff

Critical care and cardiovascular review course focusing on cardiac knowledge, critical thinking, and advanced clinical care

Classes designed to prepare staff for CCRN, ANCC Cardiovascular Certification, and other clinical certifications or registry examinations

Level 5—expert practitioner

Reserved for certified, registered, or master’s-prepared practitioners

Recognized as clinical experts and may participate as instructors for other levels in the Novice to Expert Program

Bimonthly education sessions offered for continued professional and clinical growth using case study format, panel discussions, and “ask the expert” open discussion

Abbreviation: ANCC, American Nurses Credentialing Center.aReprinted with permission from Aultman Hospital, Canton, Ohio.



37Copyright © 2011 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.

Table 4: Aultman Heart Center Curriculum Novice to Expert Levels 1 to 4a

Level Classes

Level 1 Cardiac dynamics and assessment—part 1 Acute coronary syndrome

Cardiac dynamics and assessment—part 2 Interventional cardiology

Cardiovascular pharmacology—part 1 Open heart surgery

Cardiovascular pharmacology—part 2 Infection control/infectious disease

Introduction to 12-lead ECG—part 1 Heart failure

Introduction to 12-lead ECG—part 2 Noninvasive cardiac testing

ECG injury and ischemia Introduction to device therapy

Axis/bundle branch block—ECG review Introduction to pacemaker rhythm

Interpretation and TTVP troubleshooting

Level 2 Advanced cardiac physiology Hemodynamic fundamental and altered

Heart sounds and physical assessmentphysiology

Hypertension and diabetes management in the Inflammatory diseasecardiac patient

Fluid/electrolytes/renal Valve disease

Arrhythmia interpretation Cardiomyopathy

ECG fundamentals and axis interpretation Pulmonary physiology and acid base

Bundle branch blocks/hemi blocks Concepts of ventilatory and oxygenation

Ventricular ectopysupport

Cardiac risk factors

Cardiac rehabilitation

Level 3 Pulmonary physiology and oxygen delivery Pacemakers

Pulmonary pathophysiology ICDs and cardiac resynchronization

Neurovascular disease (ischemic stroke)therapy

Peripheral arterial disease Nonpharmacological treatment of

Narrow complex tachycardiasarrhythmias

Wide complex tachycardias Antiarrhythmic pharmacology

Injury and ischemia Advanced hemodynamics and assessment

Myocardial mimics and normal variants Pharmacology and hemodynamics

Hematology and coagulation

Critical care patient management

Level 4 Certification preparation workshop

Synergy model/certification overview Endocrine

Oxygenation/pulmonary physiology Renal/fluids/electrolytes

Ventilatory support Advanced ECG review

(continues)



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certification preparation course, staff membersreceive a certification packet that includes theAACN Certification Exam book and an orienta-tion to available study resources. These resourcesinclude the CCU lending library/resource room,

which has a computer for online independentlearning, CD-ROM tutorials, cardiac/critical careresource manuals, and articles available for sign-out.

Formal study groups have been implementedby the unit-based CNS after completion of the


Table 4: Aultman Heart Center Curriculum Novice to Expert Levels 1 to 4a (Continued)

Level Classes

aReprinted with permission from Aultman Hospital, Canton, Ohio.

Abbreviations: ECG, electrocardiogram; ICD, implantable cardioverter defibrillator; MODS, multiple organ dysfunction syndrome; SIRS,systemic inflammatory response syndrome; TTVP, temporary transvenous pacemaker.

Figure 1: Aultman Hospital Heart Center Staff Education Committee. Used with permission from AultmanHospital.

Acute coronary syndrome—acute management and secondary prevention

Advanced ECG—injury and ischemia

ECG variants

Hemodynamic assessment (invasive and noninvasive)

Shock states

Pharmacology and hemodynamics

Intra-aortic balloon pump

Advanced pathophysiology

Heart failure

Valve disease

Cardiomyopathy

Inflammatory disease

Advanced device management

Advanced arrhythmias

Antiarrhythmic pharmacology

Electrical management

Gastrointestinal/liver/pancreatitis

Sepsis/SIRS/MODS

Toxic exposure

Coagulation and hematology

Diseases of the aorta

Trauma

Neurological conditions (hypothermia)

Pulling it all together—practice and examination preparation




Table 5: AACN Synergy Model for Patient Carea

Patient characteristics

Resilience The capacity to return to a restoration of functioning using compensatory mechanisms; the ability to bounce back quickly

Vulnerability Susceptibility to actual or potential stressors that may adversely affect patient outcomes

Stability The ability to maintain a steady-state equilibrium

Complexity The intricate entanglement of 2 or more systems (eg, body, family, therapies)

Resource availability Extent of resources (eg, technical, fiscal, personal, psychological, and social) the patient/family/community bring to the situation

Participation in care Extent to which patient/family engages in aspects of care

Participation in decision making Extent to which patient/family engages in decision making

Predictability A characteristic that allows one to expect a certain course of events or course of illness

Nurse competencies

Clinical judgment Clinical reasoning, which includes clinical decision making, critical thinking, and a global grasp of the situation, coupled with nursingskills acquired through a process of integrating formal and informalexperiential knowledge and evidence-based guidelines

Advocacy and moral agency Working on another’s behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent inidentifying and helping to resolve ethical and clinical concernswithin and outside the clinical setting

Caring practices Nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim ofpromoting comfort and healing and preventing unnecessarysuffering. Includes, but is not limited to, vigilance, engagement,and responsiveness of caregivers, including family and health care personnel

Collaboration Working with others (eg, patients, families, health care providers) in a way that promotes/encourages each person’s contributionstoward achieving optimal/realistic patient/family goals. Involvesintra- and interdisciplinary work with colleagues and community

Systems thinking Body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family andstaff, within or across health care and non–health care systems

Response to diversity The sensitivity to recognize, appreciate and incorporate differences into the provision of care. Differences may include, but are not limitedto, cultural differences, spiritual beliefs, gender, race, ethnicity,lifestyle, socioeconomic status, age, and values

Facilitation of learning The ability to facilitate learning for patients/families, nursing staff, other members of the health care team, and community. Includesboth formal and informal facilitation of learning

Clinical inquiry (innovator/ The ongoing process of questioning and evaluating practice and evaluator) providing informed practice. Creating practice changes through

research use and experiential learning

Abbreviation: AACN, American Association of Critical-Care Nurses.aReprinted with permission from the American Association of Critical-Care Nurses.19



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level 4 certification preparation course using acase study/synergy model approach to study.Certification candidates are encouraged to part-ner with a certification “buddy” for study tips,test-taking advice, and support. Supportivehand-written notes from certified staff provide anurturing and positive way to decrease fear andbuild confidence. The CSEC instructors sharetheir personal and professional meaning of certi-fication to clinical practice within the AnnualStaff Education Program book provided to staff.

Celebrating and recognizing certified staffare critical elements toward creating the unit’sculture. Announcing a newly certified nursevia the Nursing Board for Clinical Improve-ment newsletter recognizes the nurse’s achieve-ment throughout the hospital. Recognition atthe unit level includes an all-unit e-mailannouncement, shift huddle announcementwith staff present as the certified nurse receivesa certification pin, celebration fruit or veg-etable tray during meal break, and the addition


Table 6: Linking Knowledge to Practice—Clinical Practice Expectations for Injury andIschemia (Monitoring and 12-Lead ECG)a

Practice expectation

Use appropriate lead placement for all bedside monitoring and 12-lead ECGs.

Ensure direction of QRS complex in lead aVR is negative when performing a 12-lead ECG.

Assess each 12-lead ECG for normal R wave progression.

Verify correct lead placement for all telemetry and hardwire patients at the beginning of each shift.

Use default leads for ST-segment monitoring according to unit guidelines: V1, V3, and lead III (CCU), V1, and Lead III (CPC).

Apply Heart Center Cardiac Monitoring Guidelines for lead selection for the 5-lead hardwire and 6-lead telemetry systems.

Recognize acute J point elevation MI.

Identify area of J point elevation as inferior, septal, anterior, or lateral.

Compare current ECG to previous ECG.

Identify patients who meet criteria for ST-segment monitoring.

Differentiate a STEMI and Non-STEMI by ECG.

Identify left anterior hemiblock on a 12-lead ECG.

Review 12-lead ECG as part of report in CPC, AMI � 24 hours, and with any patient with CP.

Assess V4R with bedside monitor chest lead or 12-lead ECG in all inferior MI patients.

Assess postprocedure and postsurgery ECG for changes to identify potential vessel or graft closure.

Identify the classic ECG of pericarditis and correlate with patient symptoms.

Recognize the classic ECG presentation of early repolarization.

Accurately interpret ST segments in presence of RBBB.

Use guidelines for assessing ECG changes in presence of LBBB.

Ensure LBBB is not new in any patient presenting with ischemic symptoms.

Use reciprocal depression in lead aVL to assess for early inferior injury.

Report ST segment changes of � 0.5 mm in the limb leads.

Perform posterior ECG in patients with ST depression in leads V1–V4, elevation in leads V5–V6, or any nondiagnostic ECG in a patient with symptoms.

Monitor all anterior wall MI patients for development of RBBB and anterior and posterior left hemiblock.

Assess all STEMI patients for evolution of ECG changes after reperfusion and prior to discharge.aReprinted with permission from Aultman Hospital, Canton, Ohio.

Abbreviations: AMI, acute myocardial infarction; CCU, cardiac care unit; CP, chest pain; CPC, chest pain center; ECG, electrocardiogram; LBBB,left bundle branch block; MI, myocardial infarction; STEMI, ST-segment elevation myocardial infarction; Non-STEMI, non-ST segment elevationmyocardial infarction; RBBB, right bundle branch block.



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of the nurse’s name to the certification plaquehanging on the unit’s wall of fame. Certifiednurses are recognized annually throughout thehospital during National Certification Week byadministrative letters, media publications, andunit meals. The hospital is financially support-ive of reimbursing examination fees upon suc-cessful passing of the exam.

The number of certified nurses in CCU hasincreased since the curriculum was first imple-mented. Before the CSEP, only one CCU nurseheld certification. Currently, 26% of eligible staffmembers are certified; several others were plan-ning to complete the curriculum and becomecertified by the end of the year. Engagement ofnew staff has increased since implementation ofthe individualized education plan with the major-ity completing the curriculum within 3 yearsand verbalizing commitment to obtain certifica-tion during 2011.

Integrating the “Culture”Creating a culture of certification should comefull circle and be seen at the bedside, whereexcellent patient outcomes can be measured.Aultman Hospital is a 2-time recipient of theAmerican Heart Association/American StrokeAssociation Triple Gold Recognition program.In 2010, the hospital received the Get With theGuidelines Gold Plus award for meeting heartfailure quality measures. These awards exem-plify the day-to-day commitment of the nurs-ing staff toward excellent clinical practice. TheCCU celebrated receiving the AACN BeaconAward for the third time in 2010. This unit hasachieved a 0% infection rate for ventilator-acquired pneumonia and central catheters forthe past 2 years. Excellence in clinical practiceis also acknowledged as the CCU consistentlyreceives high patient satisfaction scores.

Certified nurses are role models of bedsideexcellence and are active in efforts to implementpractice change on the unit and impact patientoutcomes. They have realized that certification isnot an endpoint but one marker along the jour-ney to practice excellence. Certified nurses aremore likely to consistently perform curriculum“practice links” versus noncertified nurses. Theyare involved in unit-based, division, and hospital-level shared decision-making councils. Manyhave become involved as CIs within the CSEP andunit-based preceptors, and with quality improve-ment projects.

The CCU is currently working to take bed-side practice to the next level and integrate the

culture into other unit processes. In the words ofAACN Past President Caryl Goodyear-Bruch,“Preparing for certification increases our knowl-edge, confidence, and empowerment to controlour practice and impact patient outcomes.”22

Unit-based competency expectations are chang-ing to incorporate the curriculum’s practice linksand nurse’s level of practice. Orientation “readi-ness” to other roles and skills, such as chargenurse and unit preceptor, are being discussed tomore clearly define and identify expectedknowledge and practice outcomes. Annual eval-uation goal-setting for CCU staff hired since2009 now includes a clinical practice compo-nent based on the CSEP practice links.

The unit’s goal is to exceed the 33% certifica-tion rate established for the facility by the Mag-net Recognition Program and move toward a100% certified RN staff. We are certain that wecan achieve that goal by continuing to linkknowledge to the bedside and building confi-dence through a supportive environment.

PVAMC Best PracticeBackgroundPortland Veterans Administration Medical Cen-ter is a 303-bed Magnet-designated facility inOregon whose mission is to honor Americanveterans by providing exceptional health carethat improves their health and well-being.Housed inside PVAMC is a complex 28-bedcombined medical-surgical critical care unitthat promotes the organizational missionthrough professional certification in criticalcare nursing (CCRN). As veterans and thepublic in general place more emphasis thanever on the safety and quality of health care,they also demand expert nursing and medicalcare. Professional certification is one way inwhich the PVAMC critical care nurses showthe veterans and their families, their employer,and colleagues that they possess advancednursing knowledge, experience, and compe-tence.23 Organizationally, certifications aid inmaintaining an effective and engaged work-force, increasing retention and recruitmentwhile enhancing professional development.24

The PVAMC critical care unit embraces theMagnet philosophy of recognizing qualitypatient care, nursing excellence, and innova-tions in professional nursing practice.25 Theunit is proud of its exceptional results in qual-ity nurse-sensitive indicators such as ventilator-acquired pneumonia, catheter-related blood-stream infections, and falls prevention.




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In early spring of 2008, the critical care nurs-ing staff expressed interest in pursuing theAACN Beacon Award for Critical Care Excel-lence. As the nursing leadership began lookinginto the award criteria, it was recognized thatthe unit’s culture around certification was inneed of improvement; only 6 (6.8%) of the 75nurses were CCRN certified. Concurrently, theVeterans Health Administration Office of Nurs-ing Services demonstrated its commitment toprofessional nursing specialty certification bylaunching the “Let’s Get Certified Campaign”in May 2008. This campaign was designed toserve as a catalyst for innovative ideas initiatedand led by VA nursing staff to develop a compre-hensive program to promote, support, reward,and recognize specialty nursing certification.24

The 2008 nursing strategic plan includedincreasing the percentage of nurses certified intheir specialty areas. Understanding the value ofcertification to patient and staff outcomes, thecritical care nursing leadership launched its owncampaign to increase the percentage of CCRNs.

Strategies for PromotingCertificationThe Inpatient and Emergency Services Divisionnursing director, critical care nurse manager, andCNS formed a team and identified a plan detail-ing the support that would be required to start asuccessful campaign to change the culture regardingcertification. To change a culture, one must under-stand the existing one. The unit’s nursing leader-ship team examined the perceptions and barriersto CCRN certification with the staff. Anecdotally,themes such as fear of test taking, not wanting tostudy and test alone, previous organizationalyears in which certification was not supported/rec-ognized, and cost of the examination emerged.Using the PVAMC-shared governance model ofinclusion and empowerment of nurses as a con-ceptual framework, strategies were identified toremove barriers to certification. These included set-ting unit goals, using interdepartmental partner-ships, and initiating unit-based study groups.

Setting Obtainable Unit GoalsGoal-setting provides a clear target for a team toaim for in addition to measuring progress andevaluating implemented strategies. Once the cur-rent CCRN rates were identified and the existingbarriers to becoming certified were understood,leadership set both short- and long-term targetgoals for improvement. These goals were incor-porated into the different phases of the Veterans

Administration’s Let’s Get Certified Campaign.An initial goal was set for 33% of critical carestaff to be CCRN-certified during phase I (May2008–May 2009) and a long-term goal of 50%by May 2010. Figures 2 and 3 demonstrate thegrowth in CCRN certification during phases 1and 2 of the campaign. Although the set targetswere not met, 23% and 35%, respectively, wereachieved. Nursing leadership quickly noted theeffects that the unit certification efforts pro-moted, including team cohesiveness, collabora-tion, and meaningful opportunities in settinggoals, and celebrating successes consistent withthose outlined in the literature.26

Interdepartmental PartnershipsIn July 2008, the critical care nursing leadershippartnered with other departments including thelibrary service and the education department.The library service obtained CDs, books, andother resources to develop a CCRN library forthe nurses to access on the unit. The educationdepartment sponsored an in-house CCRNreview course in October 2008, which featureda national speaker. Nineteen of the PVAMC crit-ical care nurses and 5 community participantsattended. Organizational support was vital ingetting the initial campaign off the ground anddemonstrated the commitment across the med-ical center to the value of certification.

Unit-Based Study GroupsA key successful strategy for the PVAMC criticalcare unit was implementation of a unit-basedstudy group. In September 2008, an 8-weekdidactic study session was developed and coordi-nated by the CNS. The weekly sessions were struc-tured using the AACN Blueprint27 for theexamination and used the CNS and certifiednurses as educators. Initially, educators wereselected on the basis of their clinical expertise. TheCNS coached each staff educator through thedevelopment of the 2-hour class. The first hourfocused on didactic content with a MicrosoftPowerPoint presentation and handouts, and thesecond hour consisted of interactive activitieswith practice examination questions, gameshow-style activities, paper-and-pencil games (eg,crosswords, word searches, definition matches),or any combination of these, which emphasizedthe principles of adult learning theory. Thesestrategies kept the staff engaged. Active partici-pation results in longer-term recall synthesis andproblem solving than verbal didactic instructionexclusively.28





Figure 2: Percentage of CCRN-certified nurses in Portland Veterans Administration Medical Center cardiaccare unit.

Figure 3: Total number of CCRN-certified nurses in Portland Veterans Administration Medical Centercardiac care unit—bimonthly.



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Each week, the study materials and staffpresentations were made available in theCCRN library and on the unit. In addition tothe didactic content, information on how tosign up for the examination and details of theLet’s Get Certified Campaign were reviewed.The campaign provided not only a discount onthe examination but also a free 1-year mem-bership to AACN.

The unit-based study sessions highlightedthe unit’s dedication to and support of thecampaign. These sessions reduced the previ-ously identified barrier of “doing it alone” and generated a team approach to seeking cer-tification. One staff participant describedthese sessions: “Studying together increasedthe morale and rejuvenated each staff mem-ber’s nursing soul.” In addition, staff membersbegan to recognize their peers for their expert-ise as educators, leaders, and mentors. Thestaff educators were able to document their pro-fessional development activities in their annualprofessional appraisals. The PVAMC criticalcare unit has continued the staff-led studygroups in both March 2009 and February 2010and offers nurses the time and tuition to attenda review course offered by the Greater PortlandChapter–AACN as well.

Keeping the Momentum andCelebrating SuccessesThe importance of recognizing certification iswell documented in the literature.26 The PVAMCcritical care unit recognizes each certificationwith a congratulatory e-mail announcementsent to all unit staff and a successful achieve-ment certificate from the nursing leadershipteam. A CCRN pin is presented at staff meet-ings or informal unit gatherings. The staff’sCCRN certificates are proudly displayed on thestaff achievement wall. This wall celebrates cer-tifications, in addition to medical center awardsand the staff’s organizational anniversaries. Theunit also recognizes the value of certificationthrough an annual cake celebration March 19to mark Certified Nurses Day (Figure 4).

Organizational recognition of certificationis critical to supporting a culture of certifica-tion. The primary incentive to become certi-fied rests with an individual nurse; financialincentives enhance support of the overall orga-nizational initiative.26 At PVAMC, a nurse iseligible for a certification award on initial cer-tification. This is a monetary award that ishonored for up to 2 initial certifications.

The PVAMC critical care unit’s great stridesin promoting a culture of certification havebeen recognized by both the national officeand local chapters of AACN. The August2009 publication of AACN Bold Voices29

acknowledged the successes of the Let’s GetCertified campaign with a specific notation togrowth in CCRNs in the PVAMC critical careunit. Locally, the Greater Portland Chapter—AACN recognized the unit at the 36th AnnualFall Symposium (2009) with a poster (Figure5) celebrating CCRN growth. Within the Veter-ans Health Administration, PVAMC was recog-nized in the initial phase of the Let’s GetCertified campaign with the first place GoldLevel Achievement Award. This top-levelaward was given to medical centers that reachthe milestone of 25% or more of all nurses cer-tified and 25% or more of direct care nursesbeing certified through creative and innovativeapproaches that support the program goal.24

The critical care unit’s participation in this cam-paign helped propel PVAMC to receipt of thisprestigious award.

OutcomesAs documented in the literature, certificationprovides recognition of the nurse’s knowledgeand expertise in a specialty area. Certificationhas been linked to empowerment. The need tocreate a work environment that empowersnurses is an important issue facing health careand the nursing profession.30 As the numbersof CCRNs have grown, so have the number of


Figure 4: Portland Veterans AdministrationMedical Center cardiac care unit staff celebratesCertified Nurses Day. Used with permission fromPortland Veterans Administration Medical Center.



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informal CCRN nurse leaders. With develop-ment of the CCRN staff–led study sessions, apool of experienced staff educators and speak-ers has emerged. Initially, the CNS served as theeducator for many of these sessions. Currently,these sessions are led primarily by the CCRN-certified staff who are mentored and coachedby the CNS. In turn, the certified staff membersencourage the noncertified staff. These rolemodels assist noncertified staff in preparing fortesting. They share study materials and helpnurses sign up for the examination.

The CCRN staff members assume manyunit-level leadership roles including unit-basedcommittee chairs and address nursing issueson the unit. Such empowerment and recogni-tion of nurses results in nurse retention. Certi-fication provides one avenue for leadership tonot only develop but also maintain its highlytrained workforce.24,28

The experience of the PVAMC critical careunit has been one of a “contagious culture.”Initially, as the first few passed the CCRNexamination, others quickly gained confidenceby watching the success of their peers. As ahealthy and competitive environment began todevelop, some senior staff members were chal-lenged by newer staff successfully obtainingtheir certification; they began taking the exam-ination as well.

As described in the literature, once a suc-cessful certification program has been imple-mented, additional specialty certifications willfollow.26 As CCRN certification became part

of the unit culture, subspecialty certificationexaminations emerged, such as Cardiac Medi-cine Certification, Cardiac Surgery Certifica-tion, and neuroscience certification (CNRN) toname a few. Currently, 11 additional specialtycertifications have been obtained by the criticalcare staff. And as stated by one nurse “becauseour unit is a large medical-surgical unit with abroad range of services, these certifications cre-ate a well-rounded and highly educated staff.”

The certification experience at the PVAMC crit-ical care unit has been extremely positive and con-tributes to a professional and healthy workingenvironment. The CCRNs were asked to reflect ontheir own certification experiences and the signifi-cance to their daily practice. One highly experi-enced nurse new to the unit stated, “Every time you prepare for an exam, you learn something that adds to your practice and benefits yourpatients’ outcomes.” Another nurse enthusiasti-cally responded about the examination prepara-tion process, “It was a good review, revived asense of collegiality, and improved my confidencein caring for more complex patients.” A thirdnurse responded about the continuing educationrequired in maintaining certification, stating,“My CCRN continues to provide me with asource of inspiration to continue professionaleducation in a variety of ways.” Anotherexplained, “CCRN is about promoting your pro-fession and having credibility among your multi-disciplinary health care team members.” Theseresponses summarize the experience and growthof the PVAMC critical care unit in its journey tocreate a culture of certification.

The Children’s Hospital ofPhiladelphia’s PediatricIntensive Care Unit BestPracticesThe Children’s Hospital of Philadelphia (CHOP),the first pediatric hospital in the nation, is a431-bed Magnet-designated organization. In2009, CHOP was rated the No. 1 pediatric hos-pital by Parents magazine.31 Children’s Hospitalof Philadelphia was featured in US News &World Report’s America’s Best Children’s Hos-pitals issue and has consistently ranked amongthe top-10 US children’s hospitals.32 The 45-bedpediatric intensive care unit (PICU) providesadvanced diagnostic and therapeutic multidisci-plinary care to critically ill children and theirfamilies. Our more than 200 PICU nurses arecommitted to patient safety and family-centeredcare.


Figure 5: Greater Portland Chapter—AmericanAssociation of Critical-Care Nurses 36th Annual FallSymposium November 2009—Portland VeteransAdministration Medical Center staff. Used withpermission from Portland Veterans AdministrationMedical Center.



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Specialty Certification GoalSpecialty certification is valued in the PICU forseveral reasons, including increasing evidencesuggesting that certification is a factor inimproved patient outcomes.4,33,34 Specialty cer-tification promotes participation in continuingeducation and professional development. Theliterature also suggests links among certifiednurses’ job satisfaction, empowerment, andimproved staff retention.24,30,35

The Pennsylvania Trauma System Foundationsets accreditation standards for hospitals caringfor trauma patients. One of the accreditationstandards is for the PICU to have 50% of thenurses who have worked for 3 years or longerbecome certified. Historically, there were alwaysseveral nurses in the PICU who were CCRN cer-tified. Efforts to significantly increase the per-centage of staff who achieved pediatric CCRNstatus began in earnest in early 2000. Followinga needs assessment, it was determined that devel-opment of resource materials and a formalreview course were needed. Pediatric intensivecare unit CCRNs were mentored as lecturers bythe unit-based CNS and a 2-day course wasimplemented in the spring 2001. Over the pastdecade, the appreciation of the value of specialtycertification has increased throughout the unit.

In 2007, 25% of eligible PICU nurses werepediatric CCRN certified. In 2009, realizingthe importance of continuing to increase thenumber of certified nurses, a small group ofnurses revisited this opportunity. This group,which included the PICU’s nurse manager,CNS, chair for the Supporting Practice andManagement shared governance council, anda unit-based education leadership nurse, part-nered to promote certification and retentionefforts on the unit. Several revisions to our cer-tification strategies were implemented.

Identifying and OvercomingChallenges to Conquering thePediatric CCRN ExaminationOn the basis of a staff survey and individualstaff discussions, several challenges to conquer-ing the pediatric CCRN examination were iden-tified. These challenges include test anxiety,limited availability of pediatric CCRN practicequestions, lack of a pediatric CCRN self-assess-ment examination, availability of funds for theexamination, individual motivation, and uncer-tainty of the benefits of certification. In addi-tion, several staff members indicated lack ofknowledge and expertise in caring for certain

patient populations, as the PICU and cardiacintensive care specialty units care for differentcomplex patient populations. Multiple pedi-atric growth and developmental considerationscan be challenging on the examination, such asunrepaired cardiac defects and differing com-mon causes and presentations of respiratorydistress from infants to teenagers. To overcomethese challenges, the nursing leadership teampartnered together to promote, support, andrecognize specialty certification.

Reaching Out to Eligible RNsCertification promotion strategies begin as staffapproach 2 years of PICU experience (see Figure 6).We individually reach out to all eligible PICURNs. Staff receive a personalized e-mail stating:“Congratulations! You are eligible for PediatricCCRN! Join us for the certification journey.”Personalized invitations to attend the PediatricCCRN Review Course are sent to each eligiblenurse. The leadership team consistently encour-ages staff to pursue certification during middleand end-of-year evaluations. CCRN materialsare distributed to staff, and flyers advertising thecourse as well as the benefits of certification areposted. Current research on the benefits of certi-fication and the AACN statements on certifica-tion are e-mailed to staff. The hospital sponsorsan annual Professional Development Fair adver-tising available specialty certifications. Duringthis time, the PICU provides information aboutbecoming a pediatric CCRN.

Two-Day Pediatric CCRN Review CourseThe PICU offers a 2-day Pediatric CCRNReview Course 3 times a year. The course ismodeled after the test blueprint. Recognizingthat despite the best of intentions, many peo-ple fail to follow through and take the exami-nation following a review course, PICU nursesmust now register for the CCRN examinationbefore attending the review course. Once reg-istered, attendees receive paid conference daysto attend. Attendees receive 14 PennsylvaniaState Nursing Association–approved continu-ing education credits, including trauma hoursbased on the percentage of trauma topics cov-ered during the course.

The course includes practice questions, studypreparation hints, and test-taking tips. All pre-senters are pediatric CCRNs and participate inthe development of practice test questions. Inpartnership with nursing staff from the cardiac




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intensive care unit, the cardiac portion of thecourse is taught by experienced cardiac inten-sive care unit CCRNs. Practice test questions areincorporated throughout all presentations. Thereview course also includes 2 separate half-hourpresentations based solely on practice questions.Staff comments on the course evaluations haverevealed that the practice questions are helpfuland that more questions were desired to helpbetter prepare for the examination.

Unit-Based ResourcesGrowing our certification resources is a priorityfor the leadership team. Examination prepara-tion resources such as review materials, practicequestions, books, flash cards, and CDs are storedin the PICU library. Certification handbooks andRenewal by Synergy CERPs pamphlets are avail-able on the unit. A Pediatric CCRN GuardianAngel card is distributed to staff with encouragingwords, while staff study and prepare for the exam-ination. Most importantly, pediatric CCRN peersare extremely influential. Peer support is identifiedin the literature as a motivator for nurses to pur-

sue certification.33 Peers support and encourageothers along the certification journey. CCRNpeers help to take the mystery and fear out oftaking the examination by sharing how they pre-pared for the examination and what the exami-nation was like for them. In the spirit of healthycompetition, we post the number of certified nursesin each of the 7 nursing teams on the unit. Thisallows staff to see how their team compares withother teams on the unit. As more nurses becomecertified, more nurses want to be certified.

Unfortunately, not everyone passes the pedi-atric CCRN examination on the first try. Withpeer support, there is more transparency andwillingness of staff to talk about not passingthe examination. A network exists where peersshare examination topics and strategies to passthe examination on the second attempt.

Congratulations! Next Steps for RecognitionRecognition is an important factor in certifica-tion promotion.3,16,36 Achieving certificationstatus is recognized both within the PICU and


Figure 6: Certification promotion strategies.



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hospital-wide. The hospital offers a certifica-tion bonus for all newly certified RNs. Hospi-tal-wide nursing-shared governance councilspartner to sponsor a certification breakfastduring the annual professional developmentfair. Certified nurses from different practiceareas are recognized during these events.

New CCRNs are announced at unit staffmeetings and receive recognition “Bravo Cards.”Congratulatory e-mails notify all PICU staff thatwe have new CCRNs, and the names of newlycertified nurses are sent to the tristate NursingSpectrum magazine. The PICU’s recognitioncommittee distributes gift bags and updates abulletin board with names of certified nurses.Achieving CCRN status is reflected in nurses’individual annual evaluations under the corecompetency categories of “delivering excel-lence” and “commits to service.” Once nursesare certified, we give them preference to func-tion in charge, clinical resource, or intravenousplacement nursing roles.

OutcomesOur unit experienced a surge of 25 newly certi-fied pediatric CCRNs in 2009. We attribute thishuge success to 3 critical factors: peers present atreview courses and provide support for futureCCRNs, increased recognition and celebrationof achieving pediatric CCRN status, and CCRNexamination registration is required beforeattending the review course to ensure that nursesare fully committed to the certification journey.Currently, we are tracking the percent increasein pediatric CCRNs and the certification exami-nation pass rate after RNs attend our reviewcourse. In April 2010, the PICU had 49 CCRNs(35% certified staff) of the 139 eligible RNs. Asof July 2010, there are 52 CCRNs of the 146 eli-gible RNs (the PICU certification status remainsat 35%). Eight PICU nurses are currentlypreparing for the examination; we anticipate anincrease in PICU CCRNs by the fall of 2010.The examination pass rate in 2009 was 83% (25of 30 staff passed the examination).

To determine which examination prepara-tion resources are the most helpful for staff asa whole, we are in the process of resurveyingthe staff. We will use these results to determinestrategies to effectively revise our certificationpromotion and examination preparationresources. Our specialty certification goal is toincrease the number of eligible PICU nurseswho successfully achieve pediatric CCRN cer-tification by 15% by June 2011.

Staff members in the PICU at CHOP contin-ually strive to provide excellent clinical andfamily-centered care to all patients and families.Specialty certification demonstrates both acommitment to the provision of safe, excep-tional patient care and the continuous learningand professional development of staff. Variousstages of the certification journey are sharedamong nurses throughout the PICU, and bothformal and informal support systems haveevolved. The achievement of certification iscontagious. As more nurses become certified,we will further develop support systems forcertification achievement and renewal andanticipate our certification culture to thrive.

SummaryNTI’s 2010 Creating a Culture of Certifica-tion: Best Practices Roundtable provided aforum for nurses to share and discuss success-ful experiences and strategies for encouragingnurses to take the certification journey. Threediverse practice environments (a CCU, a med-ical-surgical critical care unit, and a pediatricintensive care unit) share common certifica-tion themes including the 5 themes identifiedby AACN’s best practice units: commitment toexcellence, supportive and encouraging environ-ment, setting a goal/goal-directed evaluations,available resources, and celebration/rewardingexcellence. All 3 of the hospitals highlighted inthis article embraced these themes using differ-ent but successful approaches.

AcknowledgmentsThe authors thank Leslee Dennis, Aultman Corporate Communications; Cheryl Hecht, RN,MSN; Patricia Hubbs, RN, MSN, CCRN; KarenMarzlin, RN, MSN, CCNS, CCRN-CMC; FlossJ. Mambourg, MS, MPA, RN, NEA-BC;Jeannette Richardson, RN, MS, CCRN, CNRN,CNS-BC; Kathryn Roberts, RN, MSN, CNS,CCRN; and Cynthia Webner, RN, MSN, CCRN,CCRN–CMC, for their assistance in the review ofthis manuscript.

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