Quantifying Credentialing in Nursing

By Dean Bobbie Berkowitz, PhD, RN, FAAN

The nursing workforce, which is the largest sector of health professionals in the United States, is comprised of individuals with varying educational backgrounds and expertise, representing many specialties and subspecialties. While a wide range of credentialing organizations award nurses with certification for their additional education and training, it has not been definitively demonstrated that the credentialing process has an impact on health care quality. The question whether credentialed nurses can improve the quality of care in the country is important because not only does the quality of care vary widely from one geographic area to another and across demographic categories, but according to the Agency for Healthcare Research and Quality, only about 70 percent of the population receive adequate care. 

Broadly speaking, the concept has three categories. The entry-level credential takes the form of initial licensing by state boards of nursing and affirms that basic skills are present. Second, special skills or training certification ensures proficiency within various nursing specialties, such as critical care nursing. Third, advanced practice certification is granted through licensing by state authorities to nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists.

Adding complexity to the picture is that nurses are certified on diverse standards and criteria from numerous professional organizations. Not surprisingly, achieving uniformity among them has proved elusive to date. But more basically, while it may appear intuitive or even obvious that a specialty credential leads to better patient results, the research evidence is limited due to practical and methodological problems. As a result, many of the existing studies are descriptive or correlational; even their findings are inconsistent.

To bring clarity to this question the Institute of Medicine convened the Standing Committee on Credentialing Research in Nursing in 2012 to discuss issues related to research on credentialing of nurses. One of our committee activities to examine topics related to research frameworks, knowledge and methodological gaps, research priorities, and strategies. To encourage activity into the question of nursing credentialing research we invited experts in this field to convene at a workshop in 2014. As chair of the workshop Planning Committee, I’d like to provide a summary of the current thinking of some of the nation’s experts on the topic of nurse certification.

Attending the workshop in Washington, DC were more than 100 individuals from 20 different organizations.  The workshop report that resulted, Future Directions of Credentialing Research in Nursing, identifies several themes to guide future research on nurse certification. These include:

  • Universal research framework: A common conceptual model would be useful in helping to frame important research questions that respond to the different but related needs of nurses and patients. For example, it is important to determine whether certification itself affects health-related outcomes or is a marker for other factors that influence outcomes.
  • Improved data gathering: More standardized data, performance measures, and data collection procedures are needed to increase the applicability of research findings as well as promote comparisons between institutions. As discussed in the workshop, an agreement on commonly used terms is crucial to increase our ability to generalize findings; it will also lessen confusion among patients and nurses themselves.
  • Emphasis on causality: Research designs and methods could explicitly explore possible causal links between certification and better patient results. For example, we could examine if certification encourages evidence-based practices, leading to improved outcomes.
  • Changing roles of nursing: Research that examines the effects of public policy, payer, demographic, and technology changes on credentialing across different health care delivery structures and care settings could lead to a better understanding of the potential influence of a specialty credential.

The implications of enhancing the certification process are considerable. For example, if research does establish that credentialing results in better care, efforts to expand scope-of-practice opportunities in nursing could be enhanced, prompting more nurses to pursue advanced degrees.

Realizing such benefits will require extensive effort and cooperation among many parties. This of course will not be easy. Therefore it is encouraging that advances in data collection, health informatics, data infrastructures, and research design show promise for credentialing research in nursing.  For example, “big data” offers the prospect of new and faster methods for aggregating and mining data and recognizing patterns. These opportunities, however, require additional resources. As any hospital attempting to interlink its legacy software systems knows, upgrading data environments to improve interoperability is expensive. Pooling and sharing data across institutions will be even more logistically challenging and financially burdensome.

Many innovative suggestions were presented at the workshop and new relationships forged. Participants are armed with fresh enthusiasm for taking these ideas beyond the conceptual phase. 

Because the stakes are so high, I will work to ensure that the questions, issues, and proposals raised at the workshop remain at the forefront of discussion in academic, professional, and public policy settings.