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

Chapter: 6 Nursing Credentialing Within a Complex Health Care Landscape

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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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6

Nursing Credentialing Within a Complex Health Care Landscape

THE FUTURE OF NURSING, CREDENTIALING, AND EFFORTS TO IMPROVE QUALITY

Susan B. Hassmiller, Robert Wood Johnson Foundation

The Institute of Medicine’s (IOM’s) 2011 report The Future of Nursing: Leading Change, Advancing Health was followed by a large national campaign, mostly funded by the Robert Wood Johnson Foundation (RWJF). The campaign has generated action coalitions in every state that are working to implement the report’s recommendations, most of which related to practice, education, and leadership. The activities of these coalitions inherently have implications and opportunities for credentialing research, began Hassmiller.

Nursing credentialing research could affect adoption of the IOM recommendation that Advanced Practice Registered Nurses (APRNs) should be able to practice to the full extent of their education and training. A number of states are working on initiatives related to scope of practice, which the campaign viewed as barriers to practice and care. Six states (Connecticut, Minnesota, Nevada, North Dakota, Rhode Island, and Vermont) have given APRN’s full practice and prescribing authority since the Campaign for Action began, bringing the total number of states allowing full practice and prescribing authority to 19, plus the District of Columbia (AANP, 2014; Hassmiller, 2014). Four other states have made incremental improvements in that direction. If nursing credentialing signals high-quality APRN training and individual competence of advanced practice nurses, then removal of scope-of-practice barriers for credentialed individuals may be beneficial, said Hassmiller.

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

Evidence demonstrating that credentials involving higher education levels and lifelong learning initiatives lead to improved performance could accelerate trends by nurses to seek doctoral degrees, suggested Hassmiller. The RWJF campaign is working toward the IOM recommendations related to academic progression. Its goal is that at least 80 percent of nurses should have at least a bachelor’s degree by 2020 (IOM, 2011). In addition, the RWJF campaign seeks to increase the number of nurses with doctoral degrees, implement nurse residency programs, and promote lifelong learning. Hassmiller reported that, since the IOM report was published, the number of students enrolled in the American Association of Colleges of Nursing’s Registered Nursing to Bachelor of Science in Nursing (RN to BSN) programs has risen more than 50 percent, and 30 states have adopted promising models to strengthen nursing education (Hassmiller, 2014). These efforts are supported by such programs as Medicare’s Graduate Nurse Education Demonstration program and by the support for BSN education within the Magnet recognition program.

A third campaign priority is to bring more nurses into leadership positions in health care, in large part, because nurses bring a unique perspective to management and policy discussions. Nurses spend the most time with patients, and they are the largest segment of the health care workforce. As such, they are vital to improving health care quality. Yet, American Hospital Association data show nurses account for only a fraction of hospital board positions. Nationally, the campaign’s goal is to place 10,000 nurses on boards by 2020. Again, credentialing research might show that nurses have certain skills that translate to effective leadership.

While legitimate emphasis is put on linking credentialing to patient outcomes, that research is difficult. In some cases, said Hassmiller, “process indicators can be just as important as the end result.” She pointed to the example of interprofessional collaboration. Although much still needs to be learned about interprofessional collaboration, RWJF is closing down 10 of its most significant, discipline-specific human capital leadership programs in favor of “new health-focused leadership programs that connect people across sectors as well as disciplines” (RWJF, 2014). These new programs will include interdisciplinary and team-based initiatives.

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

ENCOURAGING NURSING CERTIFICATION AND ASSESSMENT IN HEALTH CARE ORGANIZATIONS

Kathleen Gallo, North Shore–LIJ Health System

The North ShoreLong Island Jewish Health System (North ShoreLIJ) is a highly integrated system that offers the full continuum of care, including outpatient, inpatient, ambulatory, long-term, home, and hospice care, began Gallo. It is the largest employer and largest health system in New York State. It is also a large educational enterprise with 120 residency programs, a new medical school, and plans to develop a graduate school of nursing. Like other large health care institutions, North ShoreLIJ is undergoing a massive transformation to prepare itself for the new health care landscape. Central to its activities and to successfully managing these transitions is a high-quality workforce.

In addition to providing clinical skills training, the Center for Learning and Innovation has a “business school,” which includes leadership development programs and other skills development intended to “create a pipeline of leaders in our organization,” Gallo said. One program focus is on improvement sciences, in which many categories of employees are trained in Six Sigma and Lean black-belt programs, as well as microsystem improvements. Engineers are embedded in many teams to help in the redesign and transformation of clinical practices.

North ShoreLIJ is committed to many of the recommendations in The Future of Nursing, such as enabling APRNs to practice to the full extent of their education and training. To underscore this commitment, North ShoreLIJ offers increased pay for every specialty certification its RN staff receives. Additionally, the organization offers a year-long nurse fellowship that transitions the new nurse graduate into specialty care practice units. This program also prepares nurses for specialty certification,1 similar to the nurse internship program recommended in The Future of Nursing. In addition to theoretical and clinical curriculum, the program has embedded mentoring and socialization into the work unit as a standard. In combination, all of the organizational outcomes have been positive, in terms of retention and quality measures, and one-quarter of the nurse fellows are specialty certified.

She recognized that the research on quality differentials with additional certifications is not yet definitive, but indicated that North ShoreLIJ was “fully committed to it, with or without the research. It just makes

__________________

1Programs are offered in critical care, emergency care, pediatrics, and pediatric hematology/oncology, perioperative services, maternity care, and others.

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

sense to us.” Specialty expertise makes a difference because the knowledge, clinical skills, and clinical judgment acquired improve patient care and maintain clinical skills, which normally deteriorate over time. “It is a proxy for competence,” she said. North ShoreLIJ is in the early development stages of creating the infrastructure for the collection and analysis of interprofessional health care workforce data.

As described by Hassmiller, The Future of Nursing included a recommendation that the number of nurses with baccalaureate degrees increase. For the past several years, all new North ShoreLIJ nursing hires have had their baccalaureate degrees. Any associate degree nurse working in the system has 5 to 7 years to obtain a BSN degree, and the system pays for the additional education. The system also is working to double the number of its nurses with doctoral degrees by 2020.

DEVELOPING A NATIONAL FOCUS

Kenneth W. Kizer, University of California, Davis, Health System

The need for health care to become more integrated has been increasingly recognized in recent years as a means to achieve better care and better health, Kizer explained. In order to align the focus of nurse credentialing research with these national health policy goals, research in these areas must be prioritized, he said.

He further noted that, although there is currently no standard definition for “integrated care” or “integrated delivery system,” it is important to understand that the two are not equivalent. Creating integrated delivery systems will not necessarily lead to integrated care. As examples of delivery systems that were “integrated from an administrative and financial perspective,” but not integrated clinically, Kizer cited the U.S. Department of Veterans Affairs (VA) health care system of the early 1990s and the military health care system. Much of the transformation of VA health care in the late 1990s was aimed at achieving clinical integration.

In general, an integrated care model has been shown to be superior to nonintegrated care in achieving higher quality and better health care value, and requires the following seven core functionalities:

  1. A clearly articulated and common vision of health care service delivery;
  2. Information management tools and other infrastructure to monitor, analyze, and affect clinical processes and outcomes;
Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×
  1. Team-based care;
  2. Methods of clinical and other accountability;
  3. Strong clinical leadership;
  4. Aligned interests across providers, including shared financial risks and rewards for clinical outcomes; and
  5. A patient-centric and population health focus.

What credentials were necessary for nurses and other clinicians working in different parts of the health care system in order to improve quality and value, asked Kizer. With the national focus on promoting integrated care, it is more important to be able to determine how nursing credentialing either enables or contributes to the core functionalities of integrated care by answering the following research questions:

  1. Does credentialing in its various forms facilitate more integrated care?
  2. Does care from a credentialed individual or entity produce quantifiably superior outcomes, which the marketplace finds valuable and will reward?
  3. Is nursing credentialing sufficiently standardized to allow payers (and providers) to know which types of credentialing will achieve benefits worth investing in?

To develop a national focus for credentialing research, it is also important to establish how nurse credentialing promotes a health care culture of excellence that achieves a level of superior performance that would qualify as “world class.” A congressionally mandated review committee, chaired by Kizer, defined a “world class” medical facility (Kizer, 2010) as one that meets a list of criteria delieanated in 18 categories that fall into the following six domains:

  1. basic infrastructure;
  2. leadership and culture;
  3. processes of care;
  4. performance;
  5. knowledge management; and
  6. community and social responsibility.

Kizer added that, while these structural elements were necessary to a culture of excellence, “they were not in and of themselves sufficient” as

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

they did not capture the “invisible architecture”—the values, the culture, the emotional climate, and other intangible aspects—of an organization that are presently impossible to measure but are essential for achieving a level of performance excellence that would quality as world class. “That invisible architecture creates the soul of the organization and catalyzes the synergies that occur between physicians and nurses and other caregivers that lead to world-class excellence,” said Kizer. Thus, the final research question for nursing credentialing research is to what degree, or how, does nurse credentialing promote this catalytic interaction among providers, the facility’s physical environment, and technology to achieve a culture of excellence in health care?

GETTING FROM RESULTS TO PRACTICE AND POLICY: IMPLICATIONS FOR IMPLEMENTATION

Sheila A. Haas, Loyola University of Chicago

The adoption of evidence-based practice guidelines by individual nurses and health care organizations is not easily accomplished, but can be facilitated by translation science, which investigates the “methods, interventions, and variables that influence adoption” of clinical practices, Haas began (Haas, 2014, citing Titler, 2008). Research in this field aids the “movement between patient- and population-oriented researches,” leading to “improved patient outcomes and community health, and implementation of best practices,” she explained (Haas, 2014, citing Rubio et al., 2010).

While care at the population level is grounded in evidence-based practice alone, care of the individual patient must also account for context-specific variables such as the patient’s preferences and values and the health care team’s attitudes and beliefs. If these variables are not accounted for, it will be difficult to “integrate novel, evidence-based protocols into the culture of an organization or unit,” said Haas. As a result, “practice will not change” and outcomes will not improve.

To illustrate the importance of contextual variables in the adoption of new protocols, Haas provided the example of hand hygiene:

Everybody has the knowledge as to why you wash your hands. We have the skills to wash [our] hands. Even kids in Kindergarten can do it. Yet we have 60 percent compliance in health care. Why is that? It is all about attitude.

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

According to Haas, the use of “theory within translational research” offers a way to identify attitudes and other contextual variables, and to develop strategies to control for them. Strategies derived from theory also help to make newly adopted practices sustainable within, and transferable among, organizations. Thus, by elucidating the manner in which research findings can be applied to care protocols, translational research renders transparent the “black box of implementation.”

Yet, translational science remains an unfulfilled promise. In part, this is because many nurses have limited knowledge of the field. Translational science and evidence-based practice have only recently been added to the curricula of nurse training programs. Even Doctor of Nursing Practice students and nurse educators are inconsistently trained in translational science. The limited success of translational science is also due to the attitudes of traditional nurse researchers who, Haas claimed, see it as a “less rigorous form of research,” and ignore its ability “to generate large and reliable data sets that cross entire populations.” Finally, progress in translational research has been stymied by a lack of fully integrated electronic health records (EHRs) with internal architecture sufficient to support standardized coding of documents. Also lacking are leaders that recognize this problem, and informaticians who can correct it.

To surmount these obstacles, Haas recommended the following actions:

  • Encourage nurse educators to learn, appreciate, teach, and facilitate translational research;
  • Encourage nurse faculty to engage in translational research; and
  • Transition to EHR internal architecture that supports use of standardized coding by producers and vendors of EHR software.

If these policies are enacted, Haas said that translational science will advance and health care as a whole will benefit from “sustained implementation and ongoing evaluation of best practices, as well as improvements in patient outcomes and health care safety.”

QUESTIONS AND COMMENTS

What advice can the panelists offer for moving forward with a nursing credentialing research agenda?

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

Do not let the perfect be the enemy of the good, repeated Hassmiller. There are finite resources for research, she said, and a balance is needed between advocacy and research. If research is not affecting policy and practice, or if advancing a research agenda depends more on changing policy than on furthering research, it may become necessary to “take what [research] you have and begin to look at the communication, the messaging, and advocacy in order to make a difference.”

Gallo said, “You have to appeal to the marketplace and convince big employers, payers, and government that credentialing equals quality and efficiency and will help them achieve the Triple Aim.” It may also be useful to determine the credentialing “tipping point”: the credentialed to noncredentialed nurse ratio at which health care teams begin to regress to the mean of credentialed practice, Gallo said.

Who should pay for the cost of credentialing: nurses, health care organizations, or the public?

At North ShoreLIJ, Gallo said, the investment in credentialing is considered a “sunk cost,” and North ShoreLIJ is not waiting for 100 percent certainty regarding the value of credentialing. Kizer added that a manager would perceive credentialing policies very differently under a global payment scheme as opposed to fee-for-service. Credentialing initiatives “will make a lot more fiscal sense” when global payment schemes are the norm, he said.

Some quality initiatives, such as those promulgated by the Quality and Safety Education for Nurses (QSEN), might move the health system forward more quickly than certification can. How do you translate these initiatives into practice?

Haas said the dimensions of an initiative must be translated into a set of knowledge, skills, and attitudes. These competencies should be integrated into nurse training and graduate coursework. Gallo added that quality and safety training initiatives are not confined to QSEN or to nursing, and that the entire clinical team should learn quality improvement skills.

ANA recognizes 14 structured data sets, whereas the Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) recognizes substantially fewer. If health care organizations are expected to code data, how will that happen uniformly and comprehensively with so many data set options?

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

Workshop participants disagreed about the extent to which SNOMED can map back to all of the nursing terminology data sets currently maintained and shared the concern that keeping the data mapping current may be an ongoing challenge for the multiple organizations that developed these various coding schemes. In addition, SNOMED staff has said that only public domain coding structures (not proprietary ones) will be included in SNOMED, said Roy Simpson.

What kinds of incentives are needed in order for nurses to voluntarily seek credentialing?

Even when nurses have the opportunity to become certified at their employers’ expense, not all choose to do so, said workshop participant Roy Simpson. Haas replied that organizations can increase participation in credentialing programs by setting the expectation that employees will obtain the credentials for which they possess the requisite competencies. This expectation should receive greater emphasis in nursing schools, suggested workshop participant Linda Lakdawala.

Linda Burnes Bolton said, “There are real costs to initial certification and keeping it up.” The “wealthier” academic medical centers cannot be the only ones to adopt a mandatory certification policy; certification must be affordable for all hospitals, she said. Even employers who will pay for initial certification may be unwilling to pay for periodic recertification, said Kathie Kobler of the National Board for Certification of Hospice and Palliative Nurses.

The demise of the fee-for-service payment system might make it easier to create financial incentives for quality, which in turn can be used to support credentialing, Joanne Spetz said. Before investing in credentials, individuals and organizations need stronger evidence showing that credentials create, or signal the presence of, higher skills, said Spetz.

To acquire this strong evidence, researchers may need to leverage other studies, said Patricia Brennan. For example, it might be possible to piggyback certification questions on the existing body of effort funded by the National Institute of Nursing Research.

Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×

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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
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Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×
Page 69
Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×
Page 70
Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×
Page 71
Suggested Citation:"6 Nursing Credentialing Within a Complex Health Care Landscape." Institute of Medicine. 2015. Future Directions of Credentialing Research in Nursing: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18999.
×
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