1. Thomas, Lynne A. BSN, RN, CGRN

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To the Editor:


The American Nurses Credentialing Center indicates that certification is a means of measuring competency, and that the identification of competent nurses will promote the public welfare by helping to ensure quality in health care. To this end, it is admirable that hepatology nurses seek recognition by defining a certification process.


While recognizing that this cohort of gastroenterology nurses provides care for those with precise disease processes, it is equally important to recognize that establishing a valid and defensible certification program, one that will promote the public welfare, is a lengthy and costly process.


This process begins with identifying the nurses who are potential candidates for the credential. Once prospective candidates (those who work in clinics with a primary hepatology practice, transplantation team members, study nurses, and others) are identified, a role delineation study, sometimes called a job analysis, must be conducted. This study defines the specific areas of practice and responsibility, called "domains," of this unique group. After responsibility domains are identified, a core group of knowledge and skills may be established, and leveled in number for each domain. This process defines the content to be tested and ensures its validity for the profession to be certified.


The time and expense to gather subject matter experts to develop a survey to be sent to potential certificants is not insignificant. Months of activity funded by tens of thousands of dollars are common. This group of specialists must represent all types of practices from across the continent in order to develop a comprehensive survey. Once circulated and returned in significant numbers, the survey results aid these practitioners in developing a test blue print. Only then may review classes or test questions be developed that encompass the specific realm and validation of practice in the specialty.


Certification is based on education, knowledge, skills, abilities, and competence, developed through experience in a specialty area of practice. Both formal educational preparation and competence in practice are key criteria for all certification programs regardless of discipline. Eligibility criteria, including a specified amount of experience, acknowledgment by other professionals that the candidate's primary area of practice is hepatology, and a content valid examination are absolutes for any defensible certification program that serves the public.


Establishing a certification program is just the beginning. A certification program that administers a credential must have a means of allowing all potential candidates equal access to programs that may be prerequisite to examination. Any antecedent review course or training process offered may not allow one candidate or group of candidates to have an unfair advantage in earning the credential.


Assessment instruments (examinations) must be consistent with the generally accepted psychometric principles. This means that after each administration of the examination, the performance of candidates on the test as a whole, and on individual items, must be evaluated statistically to insure that the test is effective in determining the competence of the candidates. Ordinarily, this review requires the input and counsel of a testing company.


A certification program must have an administrative structure to provide information, develop candidate handbooks, process applications, handle appeals, distribute certificates to successful candidates, and maintain a list of certified individuals. To manage the process and develop policy, a certification program must have a Board, which meets regularly.


Finally, as the profession changes over time, new examination items and new tests must be developed and, periodically, a new role delineation must be conducted to insure that the certification continues to be relevant.


There is no question that certification of nurses in a specialty or subspecialty provides benefits both to certified nurses and to the public.




* Validates a nurse's qualifications and competence


* Demonstrates professional aspirations and a desire to improve the quality of patient care and delivery of services


* Rewards continuing efforts to improve knowledge and skills in a profession


* Reflects a commitment of time, effort and expense to a specialty


* Provides professional recognition



More than that, a research study of the certified registered nurse workforce conducted by the American Nurses Credentialing Center in collaboration with the Nursing Credentialing Research Coalition ("Certified Registered Nurses: Results of the Study of the Certified Workforce," AJN, January 2001, Vol. 101, No. 1) provided initial evidence that certification gives nurses the "means or opportunity to practice in a manner likely to improve outcome." Certified nurses in the study "demonstrated increased confidence, competence, credibility, and control" - all attributes of high-quality caregivers.


It will be interesting to watch the evolution of activities that will lead to a new group of certified nurses joining the ranks of other nursing specialists who provide to the public competent practices by quicker responses and that have safer outcomes than those of noncertified colleagues. Certification of registered nurses in the subspecialty of hepatology is, clearly, a desirable goal. That having been said, the challenge of creating and administering such a program should not be underestimated. It will necessitate the allocation of hundreds of thousands of dollars and an equal number of volunteer hours.




Lynne A. Thomas, BSN, RN, CGRN