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This article discusses issues related to nursing certification in hospice and palliative care, such as the components of a comprehensive certification program, the benefits of obtaining the credential for both staff and employer, and preparation for certification, as well as creative methods of recognizing certified staff used by organizations nationwide. This article also explores the need for more research in relating certification to patient outcomes, as desired by the public in assisting to establish competence and public safety. The emerging discussion of continuing competence and its relationship to hospice and palliative nursing is introduced for consideration.
Hospice and palliative care has become a recognized and respected nursing specialty in the United States. Since its American inception in Branford, CT, in the early 1970s, the concept of compassionate care for the dying has broadened to include an effective model of care, incorporating medical expertise and true interdisciplinary support for patients and families. With the Medicare Hospice Benefit in 1983, the floodgates opened for growth and improvement in end-of-life (EOL) care. But with the flood came questions of quality: how do agencies ensure that nurses are well equipped to maintain high standards of palliative and hospice care? How can the public differentiate competent hospice staff and quality care from the plethora of choices available? Specialty certification is one method that has been identified to assure the public that a nurse has the knowledge and skills to provide safe, high-quality care.1 It also brings multiple benefits to the practitioner who achieves this additional credential.
But what exactly does the certification process represent? Certification is a voluntary process by which an individual can establish mastery of a certain body of knowledge as a step in the acquisition of clinical expertise in a given field. It is a formal recognition (beyond basic licensure) of advanced achievements in a particular specialty, not simply broad-based nursing knowledge. Programs of certification often differ markedly, since there are no defined regulatory statutes for certification, only standards set by a variety of certification organizations.2 Therefore, it behooves nursing leadership and the public to understand what constitutes a quality certification program and examine its validity. Most certification bodies use a third-party accreditation system, such as the American Board of Nursing Specialties (ABNS) or the Institute for Credentialing Excellence, to establish appropriate standards for sound, reliable, and legally defensible examinations.
After researching professional certification, Dominick Flarey2(pp43,44) suggests what could be considered minimum components of a quality certification program:
* connection to a professional organization dedicated to development of reputable standards and ongoing research of trends and changes within the specialty
* maintenance of an advisory board of specialists who currently practice in the defined specialty who collectively review and approve processes for granting certification to candidates
* clear definition of the meaning of certification (within the inherent scope of practice) for both its members and for society
* means to adequately verify the candidates' attainment of knowledge and skills such as valid testing methodologies
* title or standardized initials conferred to announce the certificant's status
* quality assurance measures in place to monitor the process and effectiveness of the sponsoring organization
Unfortunately, many certification or "certificate" programs do not meet these rigorous specifications. However, professionals certified in hospice and palliative care nursing can be certain that these program requirements are met within the structure and scope of the National Board for Certification for Hospice and Palliative Nursing (NBCHPN). NBCHPN is the national organization that advances quality in the provision of care to patients and families facing life-limiting illnesses through certification of health professionals. With an emphasis on psychometrically sound and valid testing structures, the certificant (as well as the general public) can rest assured that due diligence has been performed in the construction of the examination by the professional colleagues who participate in its preparation. Working with a well-established testing company ensures that the hospice/palliative care examination is statistically valid, reliable, and subject to multiple quality control procedures.3
Hospice and palliative nursing is the only nursing specialty that offers certification for all levels of hospice health professionals, including certified nursing assistants, licensed practical/vocational nurses, RNs, pediatric nurses, advanced practice nurses, and hospice administrators. Each examination's topics are based on a Role Delineation Study (RDS) in which current professionals in that particular role are asked to report how much time they spend in various tasks. These percentages are used to create the actual content outline that determines the weight of different items and issues on the examinations. The RDS is performed every 5 years for each level of the NBCHPN examinations and is a huge undertaking. This keeps the examinations up to date, relevant, and reflective of current practice.
The Advanced Certified Hospice and Palliative Nurse (ACHPN) examination focuses heavily on clinical judgment and collaborative practice, fitting the role the ACHPN plays in hospice and palliative care nursing. The Certified Hospice and Palliative Nurse examination is heavy in pain and symptom management and care at the end of life, whereas the Certified Hospice and Palliative Pediatric Nurse test has a similar focus but in the pediatric patient. The Certified Hospice and Palliative Licensed Practical/Vocational Nurse examination also focuses on pain and symptom management content as well as collaborative practice, reflective of the role of the licensed practical/vocational nurse in state nurse practice acts. The Certified Hospice and Palliative Nursing Assistant examination focuses on holistic patient care at the end of life. Significantly different, yet important, is the Certified Hospice and Palliative Care Administrator (CHPCA) examination, which encompasses concepts related to leadership, human resource management, operations, and management. Some CHPCAs are nurses, and many are not, continuing to set the specialty of hospice and palliative care apart by certification of nonnursing professionals. The breadth of these examination offerings continues to fulfill the mission of the certification board, by advancing the quality of care throughout all levels of hospice and palliative care, thus providing patients and families with the assurance that the staff has advanced knowledge at differing practice levels.
NBCHPN is also committed to supporting ongoing research, as evidenced by its commitment to a research agenda with its sister organizations HPNA and the Hospice and Palliative Nursing Foundation. There is a dearth of research on the topic of certification and actual outcomes at the bedside. NBCHPN's commitment will continue to advance evidence-based practice in relation to certification and its role in providing safe and effective care within the palliative care field.
A literature review was conducted to ascertain the identified benefits of certification. The ABNS undertook a national study to validate nurses' perceptions of the value of certification. The study identified that these personal benefits for nurses can be summarized as personal achievement, job satisfaction, and validation of knowledge; meeting a challenge; greater earning potential; commitment to professionalism; and access to a broad range of job opportunities.4 When nurses stand to gain from this type of professional development, one can assume they may stay in the field longer. This is crucial as the nursing workforce ages and shortages loom in many areas of the country.
Other authors identify personal benefits such as increased professionalism as recognized by colleagues/employers, job security, and a sense of empowerment.5 A large study by Cary1 found that certified staff felt that they had an increased potential for promotion and increased confidence in their skills and knowledge along with the aforementioned benefits.
The benefits of certification alone might be convincing enough to motivate a practitioner to pursue certification. But managers and employers have also identified preferences for hiring certified staff to enhance clinical competence and consumer confidence.6 As organizations aspire to achieve Magnet Recognition designation, certification in healthcare professionals takes on even greater significance. This element of a Magnet application will be scrutinized to see how an individual facility compares with comparable facilities.7 Certification has become an important benchmark for hospitals and healthcare entities to demonstrate competence and expertise within professional staff.
In addition, some state boards of nursing have begun to accept specialty certification in lieu of all or part of the continuing education requirement for license renewal. Texas, Arkansas, and North Carolina are just a few of the states that have added the certification option component to the renewal process.8 This emerges as further evidence that certification is considered valuable in establishing mastery of a knowledge base that reflects continuing efforts to prove competence, thus resulting in renewed licensure.
The role of continuing competence as it relates to recertification has also become a national topic of discussion. NBCHPN recognized a need for a definition of competence to guide in validating and refining certification and recertification programs. A new test form, the Situational Judgment Examination, was developed for advanced practice nurses in the specialty to test information gathering and decision making skills of the practitioner. In July 2010, the Continued Competence Committee of NBCHPN charged the Continuing Competence Task Force to distinguish between competence and competency and to craft a working definition of continuing competence. The committee sought nursing leaders from a variety of professional perspectives in addition to a public voice, which shaped the definition. This definition reads: "Continuing competence is the ongoing commitment of a registered nurse to integrate and apply the knowledge, skills, and judgment with the attitudes, values, and beliefs required to practice safely, effectively, and ethically in a designated role and setting."9 As of this writing, the NBCHPN definition has been officially endorsed by American Board of Nursing Specialties, the Hospice and Palliative Nursing Association, the Accreditation Board for Specialty Nursing Certification, the Council on Graduate Education for Administration in Nursing, the National Nursing Staff Development Organization, and the American Association of Colleges of Nursing. This working resource and call to action will guide the NBCHPN and other leaders in the field in future decisions related to recertification.
Many creative strategies have been implemented to encourage hospice and palliative nurses to become certified in the specialty. Organizational leaders often pay or reimburse for the certification examination and/or recertification process. According to a recent certificant survey conducted in August 2011, many nurses report that only initial certification is covered, and recertification is not reimbursed by employers. For those agencies who offer a clinical ladder system, points for maintaining certification may be an indirect financial incentive and recognition. Salary increases, and bonuses have also been offered to staff members who obtain the credential in some agencies. Other incentives include paid time-off for review courses, tuition to those courses, and even a paid day-off for the new certificant.10
Those organizations who see the value of certification also find unique ways to honor certified staff members. Recognition ceremonies and luncheons become avenues to honor the nurses and bestow awards, gold tackette pins, or framed certificates. Many agencies have a "wall of fame" upon which the certified staff displays the framed certificates on a prominent wall, often visible to the public. In facilities with Magnet designation, certification becomes an important marketing tool in media to promote the value of their status, as its achievement is part of the requirements to receive and maintain that trademark. These agencies more often tend to reward certified staff. Additionally, the credential is displayed on the certificant's name tag and business cards to showcase the accomplishment to patients and families. Unfortunately, these agencies are not the norm.
In the current economic climate, an unfortunate trend has occurred as many agencies have felt the need to reduce financial incentives, even rescinding salary increases and bonuses previously offered for certification. This seems to be especially true for the nursing assistant level, as all healthcare organizations look for ways to save dollars. This creates a dilemma for nursing staff at all levels and causes a challenge to the professional development of many levels of hospice and palliative care professionals. One would hope that economic recovery and increased awareness in the public sector of the value of certification would lead to a reversal of this trend. Currently, the factors that determine whether a certificant recertifies have emerged as 1) how greatly the certificant values the credential and 2) the willingness and ability to pay recertification expenses out of pocket. Hopefully, future studies will show conclusively that certification yields better outcomes and better care as well as enhancing the bottom line for agencies, and the trend may reverse.
In an ideal situation, employers will recognize and value certification, provide review courses, reimburse for such courses as well as the examination itself, and give pay raises or bonuses for certification as well as reimbursing every 4 years for recertification. In some agencies, it is a requirement to become certified in a specified period to maintain employment status. With HPNA only 25 years old and many chapters literally in infancy, the future will be likely to include more support and review courses within the chapters themselves.
HPNA has compiled several excellent tools for use for preparation for the examinations, including publications like the various core curricula and study guides available for purchase on the Internet. Self-assessment examinations for multiple levels of practice and situational judgment examinations for the ACHPNs offer opportunities to test knowledge prior to sitting for the examination. The HPNA Approved Educator course provides opportunity for experienced hospice and palliative nurses to become proficient and able to educate others in hospice and palliative content. The HPNA Approved Educator is prepared to present the Clinical Review for the Generalist Hospice and Palliative Nurse and/or the Clinical Review for the Hospice and Palliative Nursing Assistant course as one method to begin preparation for a certification examination. With more than 800 HPNA Approved Educators across the country, chapters and agencies are able to locate an instructor on the HPNA Web site to conduct review courses. Additionally, HPNA has multiple e-learning courses available, some of which are free, which may assist with examination preparation. In the NBCHPN Candidate Handbook, there are sample examination questions for each examination level as well as suggested journals that may be helpful to review (Table).
Of the 48 HPNA chapters in 28 states and the 19 provisional groups in 13 additional states, one chapter was found to have posted an upcoming HPNA Clinical Review for the Generalist Hospice and Palliative Care Nurse. Certainly, other chapters offer the course occasionally. Many hospices and palliative care organizations, especially those of larger size with multiple sites of operation and greater resources, offer review courses to staff members and may be included in the agency incentives previously listed. Additionally, there were more courses listed as certification review courses found on the Internet, although only one was associated with an HPNA Chapter. To date, it seems that most hospice and palliative professionals rely on individualized study or study groups for examination preparation because of limited access to review courses.
A baseline of 1 to 2 years of hospice/palliative care experience paves the way for the potential certificant. Studying from the HPNA Core Curriculum and Core Curriculum Study Guide for the specific examination is beneficial as well. Maintaining HPNA membership and reading the Journal of Hospice and Palliative Nursing offers insight into current issues and evidence-based practice. The potential certificant can also review key content and sample questions from the NBCHPN Web site specific to the examination. Attending a clinical review course, taking online e-learning from HPNA, and attending hospice and palliative care conferences also enhance learning.
According to Jeanne Martinez, MS, MPH, CHPN, FPCN, a quality specialist at Northwestern Memorial Hospital Home Hospice Program with a deep background of accreditation and certification leadership, "There is growing evidence that specialty certification is associated with clinical competence and improved patient outcomes."12 Continuing research related to the relationship between competence, patient outcomes, and certification is necessary to support the vital role of certification. In the years to come, with increasing consumer awareness and demand for competency in healthcare workers, professional credentials will continue to be a badge of honor and safety in the eyes of the healthcare community and the general public. The certification credential should be displayed proudly as nurses, nursing assistants, and administrators strive for lifelong learning and the highest and best interests of the patients and families who depend on this care for excellent outcomes. We applaud those who have honored the profession by achieving certification in hospice and palliative nursing.
1. Cary AH. Certified registered nurses: results of the study of the certified workforce. Am J Nurs. 2001; (1): 44-52. [Context Link]
2. Flarey D. Is certification the current gold standard? JONAS Healthc Law Ethics Regul. 2000; 2 (2): 43-44. [Context Link]
3. Fabrey L. Certification linked to practice. Presented at the HPNA Annual Assembly, Tampa, FL, January 31, 2008. [Context Link]
4. Neibuhr B, Biel M. The value of specialty nursing certification. Nurs Outlook. 2007; 55 (4): 176-177. [Context Link]
5. Wynd C. Current factors contributing to professionalism in nursing. J Prof Nurs. 2003; 19 (5): 251-261. [Context Link]
6. Stromberg M, Niebuhr B, et al.. Specialty certification: more than a title. Nurs Manage. 2005; 36 (5): 36-40. [Context Link]
7. Shirey M. Celebrating certification in nursing. Nurs Adm. 29 (3): 245-250. [Context Link]
8. Certification may apply to license renewal requirements. ONCC News. 2008;(2):4. [Context Link]
9. Continuing Competence Task Force, Bette Case di Leonardi. ABNS presentation, Austin, TX, March 2011. [Context Link]
10. Woods DK. Realizing your marketing influence, pt. 3: professional certification as a marketing tool. JONA. 2002;32(7/8):379-386. [Context Link]
11. National Board for Certification of Hospice and Palliative Nurses. Candidate Handbook. 2012. http://nbchpn.org/. Accessed October 21, 2011.
12. Martinez JM. Hospice and palliative nursing certification: the journey to defining a new nursing specialty. J Hosp Palliat Nurs. 2011; 13 (65): 529-534. [Context Link]
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