Future Directions of Credentialing Research in Nursing: Workshop Summary (2015)

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Introduction¹

The nursing workforce constitutes the largest sector of health professionals in the United States and includes individuals with varying educational backgrounds and expertise (IOM, 2011, p. xi). Like other health professions, nursing includes a large number of specialties and subspecialties. Nurses may seek certification, based on various standards and criteria, from a wide range of organizations. Similarly, organizations may participate in nursing credentialing programs, which typically reflect the attainment of various nursing care standards and outcome measures. It is, however, unclear how this additional training and education affects health care quality and patient health. As described by Hickey and colleagues (2014, p. 1), “Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited.”

To examine short- and long-term strategies to advance research on nurse certification and organizational credentialing,² the Institute of Medicine (IOM) convened the Standing Committee on Credentialing Research in Nursing, sponsored by the American Nurses Credentialing

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¹The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Institute of Medicine; they should not be construed as reflecting any group consensus.

²Throughout the workshop, speakers often used “credentialing” and “certification” interchangeably although “certification” and “credentialing” typically apply to an individual nurse and a health care facility (e.g., a hospital), respectively. This workshop summary uses the term “nursing credentialing” to capture both activities when discussing the field, in general, and to remain consistent with the planning committee’s statement of task.

Center (ANCC). Based on the standing committee’s public meetings and discussions, the ANCC asked the IOM to organize a stand-alone workshop. With guidance from a separate planning committee, the workshop was held on September 3 and 4, 2014, in Washington, DC. Twenty different organizations coalesced to sponsor the workshop Future Directions of Credentialing Research in Nursing, which examined a new framework and research priorities to guide future research on the impact of nursing credentialing and nurse certification on outcomes for nurses, organizations, and patients (see Box 1-1). More than 100 individuals participated in the workshop, and 3 background papers were distributed before the workshop for discussion purposes.³

This summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all participants, the planning committee, or the National Research Council/IOM. Text included under individual presentations in this summary is solely attributable to the speaker listed, unless otherwise indicated. At the end of each session, audience members were encouraged to ask questions of the panel. Questions and responses are included at the end of each chapter.

The structure of this summary generally follows the workshop agenda (see Appendix A), although some material has been rearranged to highlight workshop themes or to improve flow for readers. Appendix B provides a brief glossary of terms, based on definitions presented in workshop materials, which are commonly used throughout this report. This chapter includes background information about the workshop’s conception and summarizes themes that emerged during workshop presentations and discussions. Chapter 2 provides an overview of the health care landscape in which nursing credentialing occurs and introduces an existing and proposed conceptual model to evaluate related research. Chapter 3 focuses on issues related to data harmonization, performance measurement, and health informatics. Chapter 4 covers discussions related to the assessment of core competencies in medicine and

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³The three IOM Perspective papers presented at the workshop examined various aspects of credentialing research in nursing, including a conceptual framework to guide research; current barriers and opportunities in research design; and the role of data and the need for data harmonization to advance credentialing. The perspective papers (i.e., Hughes et al., 2014; McHugh et al., 2014; Needleman et al., 2014) are all available on the IOM website.

nursing. Chapter 5 includes presentations about the scientific and policy implications of implementing a research framework for nursing credentialing. Chapter 6 describes some of the existing quality improvement initiatives that could benefit from, and contribute to, nursing credentialing research, as well as some of the larger factors that could influence the timeliness and relevance of nursing credentialing research. Finally, Chapter 7 summarizes reports from the following breakout sessions:

• Using the framework to develop research priorities to advance nursing credentialing.
• Improving research methodologies.
• Short- and long-term strategies to encourage activities related to nursing credentialing research.
• Stakeholder perspectives, communication, and outreach.

The workshop concluded with seven panelists providing opinions about important takeaway messages from workshop discussions, in general.

WORKSHOP THEMES

The workshop provided attendees with the opportunity to hear and to share rich experiences, diverse perspectives, and innovative ideas to advance the field of nursing credentialing research. As workshop participants considered research priorities, critical knowledge gaps and methodological limitations, emerging research methodologies and health informatics, and strategies affecting nursing credentialing research, specific ideas and activities were often repeated in both speaker presentations and in audience discussions. Box 1-2 summarizes the emerging workshop themes. These themes capture some of the overarching ideas and considerations that could inform future decisions and activities related to the development of successful research models and programs in nursing credentialing. These themes should not be interpreted as the conclusions or recommendations of the IOM, the workshop planning committee, or workshop participants as a whole.

A Shared Research Framework

A common vision or conceptual model is needed to advance the field of nursing credentialing research by framing important research questions that respond to different stakeholder needs. A number of speakers noted that current research on the impact of nurse certification and nursing credentialing is limited and inconsistent. Robin Newhouse remarked that credentialing research in nursing is at an early stage, with many aspects needing greater clarification; the system—and the profession—need a solid research base to understand the role of individual and organizational credentialing. Determining how and whether nursing credentialing affects institutional, nurse, and patient outcomes should be a primary

goal of any national agenda for credentialing research in nursing, argued Jack Needleman.

Different audiences value different purposes of credentialing and certification, stated Needleman and Nancy Dunton. The research questions are driven, in part, by how invested stakeholders define the value of credentialing, continued Matthew McHugh. The benefit to establishing a shared research framework, remarked Needleman, is that it helps to identify new research questions in the context of different audiences and outcomes. Moreover, measurement development is dependent on the selection of appropriate research questions and a theoretical framework, stated Dunton.

Improved Data Availability, Harmonization, and Interoperability

More standardized data, performance measures, and data collection procedures are needed to improve interoperability, which could enhance research in the field of nursing credentialing. Many workshop participants noted that the ability to assess the impact of nursing credentialing requires extensive data—not simply more of it, but complex data sets with granular variables to control for numerous intervening and possibly confounding variables. Throughout the workshop, speakers noted the existence of multiple credentialing and certification organizations that used different definitions of common terms, voluntary certification requirements, and data points. This leads to the idiosyncratic collection of data in nursing credentialing, which slows efforts to compare and combine data, said Ronda Hughes. She continued, this lack of data in nursing credentialing research is compounded by proprietary restrictions. The voluntary nature of nursing credentialing and insufficient data platforms pose additional barriers, noted Patricia Dykes. Dunton mentioned important limitations in the accuracy and comprehensiveness of reported data in national data sets. Moreover, meaningful measures and metrics of nurse performance are also needed, continued Dykes.

Advancement of credentialing research in nursing depends on the ability to aggregate data sets across multiple sources, which requires data harmonization and interoperability not currently available, noted many speakers. Interoperability is important if patient-centered data collection is to be achieved, argued Patricia Flatley Brennan. To answer questions about the value of nursing credentialing, systems need structured data that

are coded using a standardized terminology and that can be exchanged electronically across systems, said Murielle Beene. To help increase interoperability and encourage more robust data systems, harmonization could start with a basic, minimum set of data elements, Beene suggested. Effective use of health information technologies could also lead to a more nimble certification process, noted Brennan.

A common data model could be used to identify consistent definitions and strategies to answer specific research questions across organizations, systems, and databases, said Beene. Expanding on this idea, Dykes suggested that a common data model could facilitate discussion of important metrics (including definitions) and variables in nursing credentialing and promote standardization of data and data collection procedures, thereby increasing interoperability in credentialing research.

Examine Causality

Determining the value of nursing credentialing requires research designs and methods that can explore the causal links between evidence-based practice, nurse certification or nursing credentialing, and relevant health-related outcomes. Identifying causal pathways allows investigators to design research that explores the link between nursing credentialing and improved outcomes, said Needleman. Patrick Romano suggested that, although causality is important, it may not be necessary to establish that a credential leads to improved outcomes; it may be sufficient to demonstrate that credentialing encourages evidence-based practices, which lead to improved outcomes.

It is important to determine whether it is the process of certification or credentialing that affects health-related outcomes or whether certification or credentialing is a marker for other factors that influence health-related outcomes, argued McHugh. For example, workshop participants discussed whether current nurse certifications and nursing credentials adequately reflect, or contribute to, a certain level of clinical competency. To make this determination, clinician competencies and training outcomes should drive curricula and assessment programs, stated Eric Holmboe. Laurie Lauzon Clabo noted that the American Association of Colleges of Nursing had created a Task Force on Advanced Practice Registered Nursing to consider core competency assessment in a new clinical training approach.

The Changing Roles of Nurses in a Complex Health Care Environment

The field of nursing is changing in response to increasingly complex and dynamic health care services across different health care delivery structures and care settings, which affects research strategies. Nurses engage in intellectually, emotionally, and physically demanding work that often involves caring simultaneously for multiple patients, said Needleman. The Patient Protection and Affordable Care Act of 2010 (ACA) has created new opportunities for nurses and research to help “better understand the role that nurses are playing,” said Ellen-Marie Whelan. Brennan suggested that some certification requirements may not adequately reflect the changing knowledge and skill sets required to practice in today’s health care environment. Moreover, emerging technologies may fundamentally change the practice of nursing, noted Brennan.

Health care provision is increasingly team oriented, which makes it more difficult to determine which patient outcomes are attributable to which health care provider, noted Needleman. Research on the nurse’s role within a care-coordination team could inform discussions of payment distributions in newer payment models, said Whelan. Many health care initiatives are targeting episodes of care for payment, said Brennan. Performance assessment methodologies must be more dynamic to respond to this changing health care environment, said Jody Frost.

Credentialing Research and Other Health Care Improvement Initiatives

Research on nursing credentialing may contribute to, as well as benefit from, diverse health care quality improvement activities within the United States. In her opening remarks, Newhouse commented on the interactive relationship between nursing credentialing research and other national health care efforts to improve quality and control costs. Linda Burnes Bolton noted that efforts to measure whether and how credentialing contributes to the overall “social good” of health promotion could help to establish the utility of credentialing research, in general. Susan Hassmiller suggested that, if research establishes that credentialing leads to improved care, such research could help to advance efforts to implement the IOM recommendations on scope-of-practice barriers in nursing and encourage more nurses to pursue doctoral degrees. Joanne Spetz

considered that credentialing may encourage more transparency, enforceability, and monitoring. Newhouse suggested that credentialing programs could be used to standardize and validate specific knowledge sets and encourage nurses to develop advanced leadership skills.

In addition to the possible contributions that it could make to other health quality improvement efforts, credentialing research may also benefit from these efforts. The ACA has expanded the sources of data available to better explain the current and future role of nurses in the U.S. health care system, expand the number of credentials, and improve credentialing research, said Whelan. Previous efforts to promote a culture of excellence and integrated health care systems could be used as a model to develop a national focus for credentialing research, said Kenneth Kizer. Robert Dittus suggested that integrating nurse certification into existing health policy initiatives to improve health outcomes, patient care, and process management could speed advancements within the field of nursing credentialing research.

However, nursing credentialing research is also somewhat subject to larger forces at play within the health care system. Kizer suggested that credentialing initiatives may make more sense when global payment schemes replace fee-for-service payments as the norm. Hassmiller advised that, if research does not affect policy or is reliant on policy change, then focused efforts on communication of existing research may be a higher priority. Kathleen Gallo noted that credentialing must appeal to the marketplace—demonstrating that credentialing will help employers, payers, and the government achieve the Triple Aim (i.e., improved patient care, improved population health, and reduced per-capita costs in health care).

Additional Resources to Advance Research

Advances in data collection, health informatics, data infrastructures, and research designs offer significant promise to the field of nursing credentialing research, remarked many workshop participants, but these opportunities require additional resources. Upgrading data environments to improve interoperability is expensive, Beene observed. Establishing both human and technological information networks across data streams and multiple stakeholders requires incentives and funding, said Dykes. Good causal research, including longitudinal studies, requires sustained funding, but the resulting evidence can attract more diverse funders, McHugh noted. He stressed the need for alternative funding strategies to

support ongoing studies and reminded the audience that the research question impacts interested funders. Needleman emphasized the need for affordable, accessible, standardized data, noting that funding for certain core activities and pilot research projects could lead to larger research programs.

The costs associated with nursing credentialing present another barrier, noted a number of workshop participants. Certification and recertification involve significant costs, which may present barriers to some hospitals, said Burnes Bolton. Employers who provide funding for initial certification may be unwilling to pay for recertification, said Kathie Kobler.

In addition to financial support, workshop participants during breakout sessions noted the potential role of independent bodies to prioritize different long- and short-term strategies. Various convening organizations could educate stakeholders about nursing credentialing and develop research questions in response to stakeholder input, said Burnes Bolton.