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December 2010, Volume 14, Number 6
The Value of Oncology Nursing Certification
Carlton G. Brown, PhD, RN, AOCN®, Cynthia Miller Murphy, MSN, RN, CAE, Vicki Norton, RN, BSN, OCN®, Patricia Donahue Baldwin, RN, MS, OCN®, and Julie Ponto, PhD, RN, ACNS-BC, AOCN®
The attainment of oncology nursing certification indicates that a nurse has the knowledge and expertise to competently care for patients with an actual or potential diagnosis of cancer. Research regarding the value nurses associate with certification is lacking; therefore, the Oncology Nursing Certification Corporation participated in a national study led by the American Board of Nursing Specialties Research Committee to explore the value of certification in a sample of certified and noncertified nurses and nurse managers. A total of 940 oncology nurses participated and completed a demographic survey and the Perceived Value of Certification Tool. Most were Caucasian women, with a mean age of 54 years; 36% were staff nurses, 19% were nurse managers, and 10% were advanced practice nurses. A high value of certification was reported. Barriers to certification included cost issues and lack of institutional reward and support. Benefits included institutional reimbursement and listing certification credentials on name badges or business cards. Both certified and noncertified nurses value certification. Increasing institutional recognition and financial support could improve nurse certification rates and ultimately may result in improved patient care.
At a Glance
· Intrinsic rewards such as validation of specialized knowledge, enhanced confidence, and professional growth motivate nurses to become certified.
· Employer-based financial support may positively influence nurse certification rates.
· Research is needed to demonstrate the relationship between certification and nurse-specific patient outcomes.
Formed in 1991, the American Board of Nursing Specialties (ABNS) sought to create uniformity in nursing certification and increase public awareness of the value of certification. The mission of ABNS (2009) is to “promote the value of specialty nursing certification to all stakeholders,” and key to accomplishing its mission is the development of a research agenda to determine the value of nursing certification. Specifically, in response to ABNS member-identified research priorities, ABNS developed the Value of Certification Study to validate nurses’ and managers’ perceptions, values, and behaviors related to nursing certification. The study aimed to address (a) perceptions of certified nurses, noncertified nurses, and nurse managers regarding the value of certification, (b) challenges and barriers to certification, (c) benefits and rewards for certified nurses, (d) the impact of certification on lost workdays, and (e) the impact of certification on nurse retention. The survey was developed and disseminated to certified nurses, noncertified nurses, and nurse managers across a wide range of nursing specialties.
Within the Value of Certification Survey, ABNS incorporated the Perceived Value of Certification Tool (PVCT), a reliable instrument measuring 18 certification-related value statements (Gaberson, Schroeter, Killen, & Valentine, 2003). Additional items focused on the identified research priorities and demographic characteristics. The ABNS survey was hosted via the Internet by ABNS’s affiliate member, Professional Examination Service. ABNS received institutional review board approval for the study. The Oncology Nursing Certification Corporation (ONCC)—a charter member of the ABNS—participated in the study, along with 19 other specialty nursing certification organizations that are ABNS members. The survey instrument and Web-based access processes were piloted by the ABNS Research Committee and two member representatives from each participating organization, including ONCC. Pilot participants’ feedback was incorporated into the final survey. As an ABNS member, ONCC was asked to invite a sample of its certified nurses and an equal number of noncertified nurses from the Oncology Nursing Society (ONS) membership to complete the final survey. A sample of ONS members who were nurse managers also were invited to complete the survey. The purpose of this article is to describe the study results from the ONCC-derived sample.
Background and Literature Review
The attainment of oncology nursing certification reflects a level of professional achievement that indicates a nurse has the knowledge and expertise to competently care for patients with an actual or potential diagnosis of cancer. Each of the seven ONCC credentials represents a specific level and focus of cancer nursing care (see Figure 1). Although nursing certification seems intuitively valuable to patients, nurses, and the institutions that employ nurses, evidence must be provided to support the benefits of certification for all stakeholders. Most evidence supporting the value of nursing specialty certification, as well as the barriers to becoming certified, has been established through descriptive studies of the opinions of nurses and healthcare managers (Byrne, Valentine, & Carter, 2004; Gaberson et al., 2003; Niebuhr & Biel, 2007; Sechrist & Berlin, 2006; Sechrist, Valentine, & Berlin, 2006).
Redd and Alexander (1997) explored the efficacy of nursing certification in terms of differences in job performance and self-esteem. They found that certified nurses had significantly higher scores than noncertified nurses as measured by the Rosenberg Self-Esteem Scale, which is important because the study’s framework was based on the concepts that an individual’s existing level of self-esteem stimulates performance to the levels needed to achieve a perceived outcome or reward. When perceived outcomes are achieved, the level of self-esteem is further increased and the individual is stimulated to continue that level of performance. Therefore, a cycle is created and the enhanced performance actually becomes the vehicle for further achievement. Using the Schwirian Six Dimension Scale to measure nursing performance, Redd and Alexander (1997) also found that, based on supervisor’s scores, certified nurses performed significantly higher on the planning and evaluation scale and had a tendency to perform higher on the teaching and collaboration scale and in overall performance scores. This study identified that the top two reasons for becoming certified were related to personal achievement and professional growth, whereas lack of experience and lack of personal time were cited as barriers to certification.
In a study of oncology nurses, Coleman et al. (1999) identified the primary reasons for becoming certified: seeking a personal challenge, a desire to be recognized as a specialist, and career development. The barriers to certification included expense, limited time to prepare, and a lack of financial reward by employers. In a similar study of critical care nurses, the main barriers to becoming certified included lack of time, fear of failing the certification examination, and lack of practice relevance (American Association of Critical-Care Nurses & AACN Certification Corporation, 2002).
Using the PVCT, Gaberson et al. (2003) examined the value of certification in their study of perioperative nurses. They found that more than 90% of respondents indicated certification enhanced feelings of personal accomplishment and satisfaction; validated specialized knowledge and professional growth; reflected a high standard of practice, professional commitment, and credibility; and provided a professional challenge.
Two studies (Coleman et al., 2009; Frank-Stromborg et al., 2002) have attempted to document the relationship between oncology nursing certification and nursing-sensitive patient outcomes. In their study of homecare patients with a cancer diagnosis, Frank-Stromborg et al. (2002) used a retrospective chart review methodology to examine the effect of oncology nursing certification on symptom management (pain and fatigue), adverse events such as infection, and episodic care utilization such as visits to the emergency department. The study included 20 nurses, of which 7 were certified, and a review of 181 patients’ medical records. Although no differences in the cited patient outcomes were found between those cared for by certified nurses and those cared for by noncertified nurses, the study provided valuable information regarding the need for additional research in this area. In their 2009 study, Coleman et al. included 93 oncology nurses (38% were oncology certified) and 270 patients with cancer and compared certified nurses with noncertified nurses for symptom management of pain, nausea and vomiting, nurse satisfaction, and patient satisfaction to determine the effect of oncology nursing certification on nursing-sensitive patient outcomes. Data were collected through surveys completed by the nurses and patients, as well as chart audits. Certified nurses scored higher on the instruments that measured attitudes and knowledge of pain and nausea management. Medical record audits revealed that certified nurses followed the National Comprehensive Cancer Network’s guidelines for chemotherapy-induced nausea and vomiting management more often than noncertified nurses (52.7% versus 48.2% [p = 0.055]). In addition, certified nurses participated in more continuing education programs and tended to have more experience than noncertified nurses.
As the literature demonstrates, certification has value in the professional development of oncology nurses and in the care of individuals with cancer, but additional research is needed regarding the role and value of oncology certification.
Design, Setting, and Sample
The current study was a secondary analysis of a larger descriptive project conducted by ABNS. The total sample size for the 20 member organizations of ABNS participating in the study was 94,768, including certified nurses, noncertified nurses, and nurse managers. From that sample, 11,427 responses were obtained for a response rate of 12% (Niebuhr & Biel, 2007). Of the respondents, 8,615 (75%) were certified nurses and 2,812 (25%) were noncertified nurses. Fourteen percent (1,608 respondents) were nurse managers.
The oncology nursing–specific sample invited to participate in the survey included 5,000 oncology certified nurses, 5,000 noncertified members of ONS, and 3,079 nurse managers, for a total of 13,079 potential participants. Only data from the ONCC subset of the ABNS sample are reported here; Neibuhr and Biel (2007) reported the results of the entire ABNS survey.
The value of certification was measured by the PVCT, developed by the Competency and Credentialing Institute (formerly the Certification Board Perioperative Nursing) (Sechrist et al., 2006). The PVCT consists of 18 items assessing the respondent’s perception of the value of certification along a five-point Likert scale. The PVCT item range is 1–4, with lower scores reflecting stronger agreement with the item, and an option to indicate no opinion (score = 0). The PVCT has demonstrated good reliability (Cronbach alpha 0.93–0.95) in certified perioperative nurses, noncertified perioperative nurses, and perioperative nurse administrators (Sechrist & Berlin, 2006).
Demographic characteristics of the sample were obtained via questions about age, gender, race or ethnicity, salary, education, current and past work roles, work setting, and employing organization characteristics. Additional items related to certification were developed by ABNS and assessed whether certification was voluntary or mandatory, the challenges and barriers to certification, the benefits and rewards of certification, the impact of certification on lost workdays, the impact of certification on nurse retention, and whether certification status was included when greeting patients. Other items included specific demographic variables and open-ended items related to barriers to certification and reasons for certification lapse. Response choices were provided, and participants could enter additional responses. The survey tool and Web-based response process was piloted by members of the ABNS Research Committee and two representatives from ONCC. Feedback was incorporated into the final survey tool.
An electronic survey was distributed to ONCC-certified nurses, noncertified ONS members, and ONS members who were identified in the ONS member database as nurse managers. An e-mail that included the Web link for the survey was distributed to potential participants, who had 30 days to complete it.
Data about demographic and work characteristics were analyzed electronically with SPSS® using descriptive statistics, including means, ranges, standard deviations, and frequencies. Using the PVCT total score for each respondent, the mean, range, and standard deviation was calculated for all respondents. Cross tabulation then was calculated to determine whether responses were evenly distributed based on demographic characteristics, certification status, work role (i.e., nurse manager versus non-nurse manager), and work characteristics. T tests were calculated to determine whether differences existed on PVCT items according to certification status. Frequency statistics were used to analyze responses to the additional questions related to certification. A minimal amount of data were missing (< 3%).
The survey was distributed to 13,079 potential ONCC and ONS participants; 940 surveys were returned for a response rate of 7%. Of the respondents, 751 nurses identified themselves as oncology certified (80%), 184 were noncertified (20%), and 175 (19%) were nurse managers. Of the nurse manager respondents, 21% were certified.
The majority of the respondents were women and Caucasian, with a mean age of 54 years. Five respondents (1%) were age 20–29, 87 (9%) were 30–39, 232 (25%) were 40–49, 411 (44%) were 50–59, 150 (16%) were 60–69, and 9 (1%) were 70 or older; 46 did not report their age. The participants primarily worked as staff nurses, advanced practice nurses, and nurse managers. On average, respondents had worked in nursing for 21.3 years and had been nurses for eight years prior to initial certification. A majority of the respondents worked in an acute care hospital, outpatient clinic, or a private doctor’s office. About 56% of the respondents earned an annual income of $50,000–$79,999. In relationship to the highest nursing degree held, 38% held a bachelor’s degree, 20% an associate degree, 18% a master’s degree, and 1% a doctoral degree. Certification remains a voluntary endeavor for 85% of respondents and mandatory for 15% (see Table 1).
The study had five primary purposes, which follow with their respective findings.
Perceptions of certified nurses, noncertified nurses, and nurse managers on the value of certification: Table 2 presents the total percentage of participants who strongly agreed or agreed with the PVCT value statements. Both certified and noncertified nurses showed a high level of agreement with all but one of the value statements—certification increases salary. A minority of certified nurses (40%) and noncertified nurses (35%) selected strongly agree or agree, suggesting that about a third of all participants related value of increased salary with certification. Respondents who were nurse managers had consistently positive perceptions of certification on all value statements.
Challenges and barriers to certification: The respondents identified barriers and challenges to obtaining and maintaining certification. The top three barriers for nurses who have never been certified included (a) cost of examination (n = 86), (b) lack of institutional reward (n = 63), and (c) lack of institutional support (n = 63). For nurses who let their certification lapse, the top three barriers or challenges were (a) inadequate compensation for recertification (n = 36), (b) no longer practicing in the specialty (n = 28), and (c) fee for renewal too high (n = 28).
Benefits and rewards to nurses for being certified: The participants identified numerous benefits and rewards to nursing certification (see Table 3). The top benefits and rewards were (a) reimbursement for examination fees, (b) listing of certification credentials on name tags or business cards, and (c) reimbursement for recertification fees. In addition, a majority of participants (81%) noted that they received some form of financial or other support from employers toward certification, but 19% noted that their employers did not offer any incentives for certification.
The impact of certification on lost workdays: Over a 12-month period, participants were absent from work an average of 2.14 days (range = 0–30 days). About 31% of participants had no lost workdays over 12 months. No statistically significant difference (p = 0.8) was found between certified (—X = 2.13 days) and noncertified nurses (—X = 2.2 days) in relationship to work absence.
The impact of certification on nurse retention: To measure potential retention, study participants were asked whether they were looking for a new employer, were planning to retire, or had no plans to change jobs. No differences were found between certified and noncertified nurses in the retention questions.
Barriers to obtaining certification included cost of the examination, lack of institutional support, and lack of institutional rewards. Reasons nurses let their certification lapse included inadequate compensation for recertification, no longer practicing in the specialty, and renewal fees being too high. These findings were similar to findings in the overall ABNS survey of all certified nurses (Niebuhr & Biel, 2007) and are similar to other studies that examined barriers to certification (Byrne et al., 2004; McClain, Richardson, & Wyatt, 2004; Sechrist et al., 2006).
Reimbursement for examination fees, listing the certification credentials on the nurse’s name tag, and reimbursement for recertification were important benefits that the participants received for certification or recertification. Of note, some of the participants never received any type of support for maintaining certification. This finding is similar to the findings from the entire ABNS survey, suggesting that certified nurses throughout the country may maintain certification on their own without any form of financial support from their employers.
In the area of lost work days, no significant difference was observed between certified and noncertified nurses. This finding suggests that no differences exist in lost workdays between certified and noncertified nurses and was similar to the overall ABNS survey findings (Niebuhr & Biel, 2007).
Clearly, both certified and noncertified nurses value nursing certification. Use of the PVCT allows researchers to understand the benefits of and barriers or challenges to achieving certification from the standpoint of nurses and nurse managers. A high level of agreement was found on all value statements except that “certification increases salary.” A low percentage of both noncertified and certified nurses agreed or strongly agreed with this value statement. A low level of agreement with this value statement suggests that increased pay unfortunately is not viewed as a value of certification, that the respondents do not view certification as a way to increase their salary, or that certification has not been a salary incentive.
This research suggests that nurse managers place a high value in nursing certification. Nurse managers agreed or strongly agreed with a majority of the value statements, suggesting that they value certification in nurses they employ. Nurse managers did note that nursing certification sometimes increases personal salary.
Nursing certification is valuable, but significant barriers exist to obtaining and maintaining certification. For nurses who were never certified, the cost of the examination coupled with the lack of institutional reward and support keep them from pursuing certification. Similarly, inadequate employer compensation for recertification plus the cost of the recertification examination were the primary reasons that nurses practicing in the specialty let their certifications lapse. Providing employer-based financial support may positively influence nurse certification rates and reduce a commonly identified barrier to certification.
The findings of this study do not appear to support a relationship between nursing certification and missed worked days and retention. Both certified and noncertified nurses missed a similar number of workdays, and neither group had significant differences in relationship to whether they were looking for new employment opportunities. Of interest, although not statistically significant, more certified nurses (12.5%) stated they were looking for a new employer when compared to noncertified nurses (10.3%). This finding, along with 87% of nurses who agreed or strongly agreed that certification increased marketability, suggests that certified nurses believe they are more marketable, lending to more confidence in their search for a new employer. Employers could retain some of the nurses looking for new employment by offering more financial incentives for obtaining and maintaining certification.
This study had several limitations, including a low response rate and potential response bias of those sampled and those choosing to participate (i.e., members of a professional organization). In addition, because this study was a secondary analysis of existing data, potentially relevant additional data items could not be collected and explored. However, the findings from this study are important for nurses, nurse managers, and employers because they identified the perceived value of certification and the benefits and barriers to the certification process. In addition, these findings are important to patients and families experiencing cancer, although the correlation between nursing certification and actual patient outcomes is less understood.
Implications for Nursing Practice
ONCC’s involvement in the ABNS Value of Certification Survey provided an opportunity to focus on the perspectives of a large number of oncology certified and noncertified nurses and nurse managers. This study has valuable implications for nurses, nurse managers, healthcare organizations, and nursing certification organizations.
For nurses and nurse managers, this study confirms earlier findings that nurses generally are motivated to become certified for intrinsic rewards and validates personal and professional meaningfulness as a result of individual certification. The respondents noted that even when they did not receive financial or other support for their oncology nursing certification, they still obtained and found personal value in that certification. However, those who did not become certified often cited extrinsic barriers, such as lack of employer support, as reasons for not opting to become certified. Certified nurses and nurse managers must continue to verbalize the importance of nursing certification and implement institutional policies to validate its significance.
This study identified benefits and barriers to certification, many of which can be controlled by employers and nurse managers. By supporting, rewarding, and recognizing oncology nursing certification, employers can encourage nurses to become certified and maintain certification. Policies should be implemented that establish oncology certification as the norm in career development. Magnet® status, awarded by the American Nurses Credentialing Center, places a high value on employer support for certification and has contributed to growing numbers of nurses becoming certified. The Magnet criteria demonstrate that nurses are attracted to an environment that supports professional development, including certification. Employers can support certification in many ways, including the following.
• Preferring to hire certified nurses
• Incorporating certification into career ladders
• Financially supporting the examination and recertification fee
• Offering paid time off for certification preparation
• Organizing certification preparation activities, such as review courses or structured study groups
• Hosting events and celebrations to recognize nurses who attain certification
• Displaying certificates in patient or public areas of the institution
• Adding certification credentials to name badges
• Increasing salary for attaining and maintaining certification
• Offering paid time off for participation in professional activities, such as continuing education or involvement in local or national organizations
• Providing opportunities for certified nurses to mentor others
About 50% of candidates for certification through ONCC in 2008 and 2009 indicated that their employers paid for certification at the time of application (13%) or through reimbursement on passing the examination (37%). To encourage employer support for oncology nursing certification, ONCC acknowledges two employers each year that provide stellar support for certification with ONCC Employer Recognition Awards. In an effort to distinguish the support that is possible from small and large institutions, ONCC recognizes one institution that employs fewer than 25 employees and one that employs 25 or more. These organizations are exemplars for others who also wish to foster professional work environments that recognize and reward the achievement of certification.
This study provides guidance for future research related to oncology certification. Future nursing research is needed to evaluate the relationship between patient outcomes and certification status of nurse providers, including whether the care provided by certified oncology nurses may significantly improve patient outcomes such as symptom prevention and relief. ONCC, in conjunction with the ONS Foundation, has funded a study to focus on patient outcomes and looks forward to those results in the near future. More research also needs to be conducted to investigate potential relationships among healthcare costs, patient outcomes, and nursing certification.
This study contributes to the growing body of literature demonstrating the importance and value of oncology certification for nurses and organizations. By sharing the results of this and other studies, nurses can help make the case for the importance of institutional support for certification.
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Carlton G. Brown, PhD, RN, AOCN®, is an assistant professor in the School of Nursing at the University of Delaware in Newark; Cynthia Miller Murphy, MSN, RN, CAE, is the executive director of the Oncology Nursing Certification Corporation in Pittsburgh, PA; Vicki Norton, RN, BSN, OCN®, is a nurse manager at Park Nicollet Methodist Hospital in St. Louis Park, MN; Patricia Donahue Baldwin, RN, MS, OCN®, is a project manager at the Veterans Administration Boston Healthcare System in Massachusetts; and Julie Ponto, PhD, RN, ACNS-BC, AOCN®, is a professor in the Department of Nursing at Winona State University in Rochester, MN. The authors take full responsibility for the content of the article. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Oncology Nursing Society. Carlton G. Brown, PhD, RN, AOCN®, can be reached at email@example.com, with copy to editor at CJONEditor@ons.org. (First submission April 2010. Revision submitted June 2010. Accepted for publication June 3, 2010.)