A Proposal for Nursing Certification Curricula, Capstone Project Example

Introduction

The foregoing prospectus outlines proposal for development of ACCN and PCCN certification curricula for the Telemetry and Step-Down units of ATH, a 437 bed hospital currently on a Magnet Journey (MJ). The 2010 MJ review of the units for nurse credentialing has been present within the institution for the last 8 months, and is being conducted in collaboration with the American Nurses Credentialing Center (ANCC) and National Certification Corporation (NCC). Magnet requires national certifications, and at present ATH is at 6%. The goal of the proposed certification curriculum is to advance the institution and its staff to 24% by completion in 2010. Framework to the curriculum is based on recommended best practices in assessment, design, training and implementation of certified protocol amongst the Hospital’s nursing employees, and will provide them with a series of classes which will serve as a blueprint for the ANCC and progressive care certification (PCCN) exams.

As standards in nurse-patient care are expanded to include evidence based practices, healthcare informatics and new IT systems, global practice models, and risk mitigation protocol, healthcare institutions are challenged to meet comprehensive care goals in ways never conceived of previously. At ATH we are confident that measures to exceed national nursing credential standards for institutions at an 80% pass rate will be met by our dedicated and competent staff. We encourage them to sit for certification.

Theoretical foundation to the ATH certification training program is primarily drawn from recommended guidelines provided by the ANCC and PCCN. Specific instructional methodologies or rubric related to telemetry and step-down practices offers content to the instructional design project, and the curriculum also benefits from secondary sources dedicated to evidenced based practices in the field of medicine, and specifically nursing protocols in the institutional healthcare environment.

Other consideration to the project is rather fresh and concept oriented, in terms of overall value to systems of nursing, and involves the potential of qualitative insights drawn from cultural research on nursing practice as international exchange becomes increasingly important in the face of nursing shortages. Acknowledgement of the trend in healthcare management information systems (HMIS) and the role of healthcare informatics (HI) in the knowledge sharing and intra-unit systems and practices in nursing and medicine, and reflects a more general concern respective to adequate and efficiency in comprehensive patient care. Sustainable and accountable patient-centric in design, the ATH Telemetry and Step-Down curriculum is the first signpost on the road to better patient care.

Background and significance of proposed project

In the United States, of practicing nurses, there are approximately 500,000 certified out of 2.9 million (Ridge, 2006). The curriculum prospectus is significant to ATH in development of a total organizational approach to internal ANCC and PCCN certification for nursing. The ATH is comprised of a 10 hospital network system, and seeks universal implementation of review and training for certifying nursing staff.

At present, the ATH is looking at the first phase in a multi-phase project, where curricula will be developed for all nursing units of the Hospital organization. Telemetry is the transmission of electronic data from one unit to another, and record of patient’ activity is monitored from central location. The centralization factor of integrated telemetry allows nursing staff to observe every patient in the unit simultaneously. Level of further recommendation from intense ICU care, to regular inpatient is deduced at this node in patient admission.

Oversight of the telemetry unit is critical to hospital systems of care, technological in scope (i,e, ECG record of heart rate), as it provides the monitoring function for vital watch of patients by machine. Basic vital information is also tracked, and IV placement is typical. Patients transferred from the telemetry or intensive-care units that are still need constant monitoring, but perhaps without electronic observation may be transferred to a step-down unit. Despite delimitation of the certification in the first phase to the telemetry and step-down units, protocol between all three units should be mapped within the framework so that contiguous systemization is not lost. Foresight will enable future expansion of the certification program as it is advanced throughout the entire institution.

Theoretical Considerations: SMPC Model

The core approach to the development of a curriculum for certified practice in ATH’s telemetry and step-down units is based on the AACN Synergy Model for Patient Care  (SMPC) recommended by the ANCC. A comprehensive program of core competencies, the ANCC SMPC incorporates the unique needs or characteristics of patients and families into its protocol for delivery of services by nurses. Assumptive within the model is that nursing competencies are matched to those required by patients, and synergy results when accountability to patient care in the clinical unit or system is optimized, as illustrated in Table 1.

The SMPC is an approach developed by the ANCC Certification Corporation for integration into its credentialing programs, and emphasizes a dual model of training for acknowledgement of nursing contributions, obligation to quality of patient care, and also operational control of costs. Other credential factors to be included in the design of the ATH framework for institutional will be focused on readying preparation for PCCN exams. The SMPC is flexible in its application, and clinical judgment issues pertaining to things like advocacy, caring practices, collaborative systems development, responses to diversity, clinical query, and facilitation of training on such topics, and allows for additional credentialing elements to be added at a future date.

Universal protocol to SMPC is concerned with the shared needs and experiences of most patients, across a wide range of illnesses and continuum in healthcare. The protocol takes into consideration the direct correlation between proficiency in nursing, and the severity or complexity in patient need, and the impact of patient’ compromise in its recommended best practices for comprehensive care. The importance of a multi-scale proficiency model within the SMPC offers CNO and other nurse administrators a long-term training application in support of nurse education, and its dimensional effects on the value of institutional systems of unit per unit guidelines for provision of that continuum. Source interpretation of competencies, where patient needs serve as the start point in a feedback loop in design of nurse competencies, increases the potential of SMPC in nurse-patient outcomes (Appendix A).

The ANCC offers a step-by-step assessment format of the SMPC model in action. For example, determination of comprehensive nursing care of a patient, a critically ill infant with multisystem organ failure is likely to include the following factors: “(a) unstable (b) highly complex (c) unpredictable (d) highly resilient (e) vulnerable (f) unable to become involved in decision-making and care, but (g) has adequate resource availability” (ANCC, 2010). By following recommendations of the credentialing body, implementation of institutional protocol by nurses will maximize the potential that all aspects of the patient’s need are analyzed and addressed. Hence, duty to fulfillment of a ‘standard of care’ as defined by both legal and best practice recommendations is far more likely than when such guidelines have not been met by required review.

Project Descriptions and Needs assessment

Impetus to the project is to determine the best channels for implementation of an ANCC and PCCN coordinated SMPC approach to establishment of training and testing preparation protocol for certification of ATH nursing staff toward the ultimate institutional goal of exceeding the national recommendation for certification of nurse-patient care practices in all units of the hospital organization.

Commencement of the multi-tiered curriculum design project encompasses unit by unit phase in of certification protocol into practice guidelines, so that universal standards of patient care delivery are adhered to, and with SMPC integration as a priority. Survey of individual nurses working in the scheduled units with an ANCC Nurse Opinion Questionnaire will be conducted in a front-end investigation of existing procedural applications and personal insights.

There is strong evidence from recent data generated from web based survey tools that indicates that segmentation research is highly beneficial to both micro and macro evaluation, as information is drawn from direct respondent insights. The potential of the data to further precision in building an apt certification curriculum for the institution will be greater, and is more likely to serve the individual institution needs experienced by our nurses. Continuity of this method will also serve in review of content and application of curricula, and inform changes made to the certification program as new guidelines come into force.

Outcomes to the Survey will offer much in terms of understanding unresolved issues to challenges within each unit, and also clarity toward retention of factors that are already successful in attending to patient needs. Both resource to organizational analysis, and confidential self-reporting of incidence that might otherwise be considered prohibitive by staff, the Survey is the initial step in a tri-partite evaluation of the telemetry and step-down units at ATH.

The pilot assessment also involves a SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis that will accompany the articulation of the unit evaluation for further integration of the findings into the curriculum design. Inclusion of the SWOT is intended as an instrument for recommendation of solutions to systemic issues, and serves as a template for expansion of the institution’s risk management strategy (RapidBi, 2010). The SWOT findings inform the final component of the tri-partite assessment, the PESTLE Analysis (Appendix B) overview of the first phase in the project. The instrument is also useful in concise rendering, and may be employed as a visual prompt in participatory, ‘brainstorming’ sessions where nurse-centric requirements are discussed in an open forum.

Both qualitative and quantitative data collected in analysis on the survey will be analyzed using SPSS (Statistical Package for the Social Sciences), with descriptive statistics to summarize unit characteristics, and item responses of participants. Inferential statistical methods will of use as patterns between the phases of unit investigation develop to form a composite picture of the institution.

Literature Review

Theoretical consideration on the ATH nursing credential program is designed according to the ANCC and PCCN credentialing bodies. Literature to the project substantiates the knowledge base of the curriculum project and looks at the five (5) areas of practice theory: 1) Discussions on the design of curriculum rubric for telemetry and step down unit training, and especially where it pertains to risk in critical care units (Craven, 2007, Kirchoff and Dahl, 2006, Ridge, 2006 and Twibell, 2010); 2) Recent literature on building evidenced based practice approaches into institutional models toward standardization of training and patient care (Miller-Hoover and Leigh, 2009 and Rauen et al., 2009); 3) Risk mitigation recommendations on lateral violence (LV) as it impacts nurse-patient response (Kendall-Gallagher and Blegen, 2009, and Sheridan-Leos, 2008) ;4) Studies on core competencies in nursing, and specifically the challenge presented in consideration of ‘universal’ protocol development for enhancing cultural synchronicity in knowledge sharing in practice settings, and the implications of international nursing exchange on both patients and institutions (Torsvik and Hedlund, 2008); and 5) Healthcare Management Information Systems (HMIS) accountability for optimization of intra-unit and institutional practice, as well as specialist knowledge sharing (Tan and Payton, 2010).

In Recognizing Excellence: Unit Based Activities to Support Specialty Nursing Certification, Craven (2010) looks at the acute care medicine unit as a point of departure for discussion on the implementation of strategies in certification training at Magnet hospitals where programs acceleration of certification are taking place. According to Craven, institutions focused on ‘ramping up’ their rates of certification where specialized unit measurements of success must be established as designated protocols, evaluation of both staff and patient indicators support analysis of cause and effect in improvement. Evidence based research should inform such decisions with demonstrated results that will benefit both patients, and sustained nurse retention.

Nursing certification as a workforce strategy, is the focus of Ridge’s (2008) query into the organizational impact of the certification as defined by the American Board of Nursing Specialties (ABNS) and with interest to organizational integration of certification protocol into the ideological framework of healthcare institutions, aligning “certification support with the mission, vision and values” of those organizations (Ridge, 2008, 50). Compensatory incentives and other practical operations measures are also discussed, and Ridge recommends priority care agendas as the basis for establishment intra-institutional standards within individual clinical practice settings, so that something like ‘Geriatric Nurse Certification’ standards in long-term care institutions serves as the primary foundation to all other training protocol. Kirchoff and Dahl (2006) further this discussion in review of the American Association of Critical-Care Nurses National Survey of facilities and units providing critical care, and suggest that the expanded scope of the AACN instrument is offering useful information for benchmarking practices; with methodological tools for testing and adjustment of response rates.

The translation of experience into adherence of procedural protocol, and also in regard to interpretation of evidenced based practice recommendations on patient care activities not restricted by stipulated step-by-step procedural guidelines, is especially pertinent to hospital transition units as patients are subject to insertion of IVs, catheter and other invasive, unsupervised procedures, says Rauen (2009), and the duty to a standard of care in this respect increases with child patients whom are recipients of venous or catheter treatments (Miller-Hoover and Leigh, 2009).

Certification training programs include appropriation of risk assessment and risk management measures into unit-by-unit accounts in clinical care activities. Competence and Certification of Registered Nurses and safety of patients in intensive care units, is of central import to the design of risk mitigation into hospital certification curricula, argues Kendall-Gallgher and Blegen (2010), and apportioned risk correlated to number of certified nurses in unit specializations is significant according to their findings. Constituted of a random sample of 29 hospitals, and analysis of 48 intensive care units revealed meaningful consistency where certification rates and staff allocation, education, experience and magnet status impacted rates of medication administration errors, falls, skin breakdown, and 3 types of nosocomial infections.

Stressors impacting nursing induced risk range from tensions between co-workers, as discussed by Sheridan-Leos (2008), Understanding Lateral Violence in Nursing, to challenges presented by the commonality of changing organizational contexts as nurses are attracted to new institutions to fulfill posts where there is the most dire need. Torsvik and Hedlund (2008) examine Cultural encounters in reflective dialogue about nursing care, in their qualitative study on international nursing exchange. Utilizing the Family Presence Risk Benefit Scale and the Family Presence Self-Confidence Scale, Twibell et al. (2010) conducted research on Nurses’ Perceptions of their self-confidence and the benefits and risks of family presence during resuscitation with outcomes showing strong interrelation of nurse confidence with invitation of family presence during such procedures. Nurses most responsive to the presence of family members indicated more association in professional organizations, certification, and experience working under duress in an emergency room setting.

With pressures to meet Magnet Journey expectations more expediently, hospital institutions are searching for more efficient systemic solutions toward advancement of certification of nursing staff. Literature on the emergence of healthcare management information systems (HMIS) as discussed by Tan and Payton (2010), in Adaptive Health Management Information Systems: Concepts, Cases, & Practical Applications; and in particular in response to effective deployment of unit healthcare informatics (HI) in established knowledge sharing domains.  A technological solution to a long-standing problem, HMIS may be the magical key to competent acceleration in certification. Without exception, HMIS IT systemization presents a method of calibrating an organization’s index with other medical providers in the national nursing certification network, and portal for exchange on recommendations in this area.

Statement of Project Need

Preface to the ATH curriculum project is cited in findings on the institution’s current low level of certification status of its nursing staff at 6%. Central to this concern, is the prevalence of risk involved in practice setting environments where standardized protocols are either not acknowledged; or not adhered to. Amidst this decision making, we have come up with a range of risk factors that ATH has projected to be costly to the institution’s finance. Mitigation of malpractice issues that might arise from lack of adherence to ANCC and PCCN certification guidelines by nursing staff are implied of those concerns as patient risk in the telemetry and step-down units is exceptionally high by nature of transitional treatments.

The core goal of the project is to advance the Hospital organization to normative levels of certification by the end of 2010, and the current magnet journey review of the Hospital’s units within the 10 institution network, is key to the decision to craft a dedicated strategy that will enable a ‘total’ institution approach to tackling this challenge. To this end, and with sights set on exceeding national levels of certification to meet our internal goal of 80% certification status, support for the project is reflected in the Hospital’s Board of Director allocation of funds to the project to meet the forthcoming requirements of this critical obligation to our patients and employees.

Project Goal

The goal of the project is to develop a SMPC model of comprehensive care within ATH institutional nursing certification curriculum, toward universal adherence to standards in nurse-patient care, and including: evidence based practices, healthcare informatics and new IT systems, global practice models, and risk mitigation protocol. Information drawn from the current MJ will enable the Hospital to integrate outcomes to the ANCC and PCCN audit(s) into comparative review with the internal assessment discussed in the preparation of unit and organizational analysis in the prospectus, and with the intention of developing a viable patient-centric care platform for nursing staff certification.

Strategies to attain goal

Strategic planning to the ATH Telemetry & Step-Down Unit Curriculum project references the ANCC framework, Nursing Skills Competency Program with appropriate integration of recommended tools to identify instructional design options best suited to evaluation and inclusion of nursing skills and skill set validation into the Hospital’s program.

Strategic development of core nursing competencies is a heightened concern at ATH. The Incorporation of materials from a range of pertinent sources from, best practices recommendations in nurse-patient care protocols evidenced based practice models, risk mitigation measures, and compliance mandated by regulatory bodies into one comprehensive set of materials toward meeting individual proficiency and institutional benchmarks in certification.

Strategic operations benefits are also presented by optimizing certification and the hospital can use this institutional accreditation to substantiate the skills of its nurses to accrediting bodies, third-party payers, and consumers illustrated in Table 2. erations enhanced through nursing certification accreditation (ANCC, 2010).

Review of accreditation application is conducted by an ANCC expert panel and is typically granted for two years, with the option to apply for renewal after the initial accreditation period.

Strategic benefits to long-term care patients involved in the SMPC care model will be derived from implementation of the ANCC’s Pathway to Excellence in Long Term Care™ (PTE-LTC) Program. The framework allows for long term care facilities to foster work environments where nurses can flourish; substantiating the professional satisfaction of nurses; and identifying the best places to work (ANCC, 2010). The PTE-LTC program has evolved out of evidenced based practice models, and organizational reviews of hospital institutions where the impact of healthy work environments on nurse satisfaction and retention shows a high degree of correlation with patient safety, patient satisfaction, and quality care.

Strategic growth for nursing staff means strategic sustainability of the Hospital, clinical services and its mission. Certifying and continuing education nurses will be involved in certification review seminars and study groups; ANCC online courses; and conferences and workshops will be supported by way of tuition and registration offsets provided by Hospital’ finance, and contribute to the menu of compensatory benefits nurses receive upon employment.

Intervention

PCCN Certification is a process by which ATH a nongovernmental agency validates credentials of nursing staff based upon predetermined standards, and individual nurse’s qualification and knowledge for practice in a defined functional or clinical area of nursing. According to the ANCC, there are over 60,000 nurses presently certified in acute and critical care nursing, internationally. Certification enables nurses to verify credential qualification to practice acute and critical care in chosen areas of specialization. Based on a standard of excellence in acute and critical care nursing, the PCCN certification process fosters knowledge development and enhances overall performance with up-to-date information on intervention and monitoring of acute and critical care patients.

Certification reinforces professional expertise and special knowledge to match level of experience, and esteems nursing contribution to the competency of employer healthcare institutions in their standing at the national and international levels. Core competencies are based upon a universal ‘Code of Ethics’ as recommended by the AACN and AACN Certification Corporation and in consideration of the American Nurses Association (ANA) Code of Ethics for Nurses foundational for nursing practice; framework provision for ethical decision making, and ‘duty to a standard of care’ in the fulfillment of responsibilities to the public, colleagues and the profession. Following the AACN Certification Corporation’s commitment to to assisting certified nurses in obligation to healthcare institutions and patients, certification substantiates that nurses have read, understood and agreed to act in a manner congruent with the ANA Code of Ethics for Nurses.

Candidates who have meet all eligibility requirements and passed the PCCN certification exam may use“PCCN” after their licensing title (ANCC, 2010). CCRN certification must be renewed every 3 years, and can be met with by way of CERP Renewal. The foregoing ATH Prospectus, Part II: Deliverables serves as an institutional strategy to the ATH PCCN certification process.

The PCCN certification curriculum at ATH is based on the AACN Synergy Model for Patient Care  (SMPC) recommended by the ANCC with inclusion of core competencies, to meet synergies in the classroom dynamic, high level learning, testing, social ethical and legal issues in nursing. Each aspect of the curriculum prospectus is designed as a blueprint for PCCN examination, and complete the strategic intervention laid forth in ATH’s directive for comprehensive service delivery. Fiscal allocation to the project in support of the Hospital’s mission and PCCN certification program is provided in the itemized budget narrative.

Budget

Evaluation of Outcomes

Effectiveness of ATH’s PCCN Certification test preparation curriculum is based upon the ANCC recommended framework for nursing certification, and augmented by ATH specialist staff and other expert insights. Attendance in the six classes by nurses whom are seeking to certify in Telemetry and Step-Down protocol, are given learning criteria for completion of the six (6) module Critical Care, Telemetry and Step-Down PCCN Certification training. Patients admitted for diagnostic in hospitalization, may be subject to a number of interventions. The course reviews the frontline admission units, and their transition monitoring functions – including EKG, IV and catheter insertion guidelines. Communications with hospital administration, physicians, RNs and patients are reviewed, as well as lexicon and record keeping to unit practice.  The goal of ATH is advancement of its nursing staff to exceed above the national mean, at a pass rate of 80% total nursing staff.

All ATH programs are measured for client service outcomes. The Hospital has strong evidence that the data generated from these tools offers nurses and hospital administration positive reinforcement in professional performance, and provides comprehensive information on the progress of unit care.  Two (2) evaluation instruments assist in tracking progress: 1) Post-test review of PCCN certification exam scores; and 2) Survey of individual nurse response to training panel, and to adherence to rules initially and annually thereafter. Audit of unit offers an operational assessment of performance, with individual activities monitored in terms of patient care and general administrative functions. CERP Review resources and updates to ANCC guidelines are available at workshops, conferences and one-day training sessions, as well as educational material on certification and institutional accreditation in the Hospital’s Library, and on the HMIS portal share network collaborating agencies, ICU units and local hospitals.

Synergy

The synergy involved in teaching the nursing profession is a continual fluid context with constant questioning the models of nursing care developed and how they relate to nursing. Synergy in curriculum development is useful in creating teaching strategies based on matching criteria with courses appropriately to meet the needs of the course and optimizing the outcomes rather than just creating a list of concepts to learn. This promotes high leveling learning in the classroom and promotes the effectiveness of teaching and testing and long-term memory retention for students. Nursing education courses modeled on synergy promote core competencies and foster knowledge and judgment while teaching the science and art of nursing.

Matching competencies in nursing and teaching facilitate learning and promote optimal outcomes. Evaluation and testing in nursing education is a measure of knowledge acquired and heighten the level of stability in complex decision making. The patient, family and nurse are all biological and psychosocial entities vacillating in various developmental stages; therefore the dynamics of all as a whole must be considered. The ethical and legal issues in nursing education are also components which work on a higher level through synergy and interrelated dimensions of the patient-nurse relationship. Clinical evaluations and clinical matters coupled with synergy are a means to restore patients to an optimal mode of healthy living. Overall synergy in teaching models contributes to the learning environment and experience in nursing.

Conclusion

In Torsvik and Hedlund’s (2008) study of international nursing exchange, nursing students were supervised during a pedagogical process. Following Schön’s theoretical approach, (1995), such studies distinguish between ‘reflection-on’ action and ‘reflection-in’ action as the delineation between conscious and unconscious practices embedded into professional performance. While nursing certification programs are first and foremost intended to support institutional accreditation, amidst the great influx of nursing resource as nurses travel to work throughout the globe wherever there are opportunities or shortages, for institutions this means that the critical need for universal measures of adherence to nurse-patient protocols is more pressing than ever.

For individual nurse practitioners, the efficacy of their professional ethics is precisely expressed in betterment of patient care. Systems of integrated knowledge sharing have created a boon for professionals seeking positive practice environments where operating policies, procedures, and management practices all contribute to their ability to work to adequate capacity in their roles, and at an optimum level of performance. The potential of ANCC’s Pathway to Excellence® Program as a next phase in institutional certification planning continues ATH’s bright prospectus toward a future of global patient care.

References

American Nurses Credentialing Center (2010). Retrieved from: http://www.nursecredentialing.org/default.aspx

Craven, H. (2007). Recognizing Excellence: Unit-Based Activities to support specialty nursing certification.  MedSurg Nursing, 18(6), 367-371.

Kirchoff, K.T. (2006) American Association of Critical-Care Nurses’ national survey of facilities and units providing critical care. American Journal of Critical Care, 15(1), 13-28.

Miller-Hoover, Suzan and Small, Leigh. Research Evidence Review and Appraisal: Pediatric Central Venous Catheter Care Bundling. Pediatric Nursing 35.3 (2009): 191-201.

PESTLE/SWOT (2010). RapidBi. Retrieved from: http://www.rapidbi.com/created/the-PESTLE-analysis-tool.html

Rauen, C. et al. Evidence-Based Practice Habits: Transforming Research Into Bedside Practice. Critical Care Nurse 29.2 (2009): 46-60.

Ridge, R. (2006). Nursing Certification as a workforce strategy. Men in Nursing, 50-53.

Schön, D. (1995) Think in Action. Aldershot: Arena.

Severinsson E.I. & Hallberg I.R. (1996) Clinical supervisors’ views of their leadership role in the clinical supervision process within nursing care. Journal of Advanced Nursing 24(1), 151–161.

Sheridan – Leos, N. (2008). Understanding Lateral Violence in Nursing. Clinical Journal of Oncology Nursing, 12 (3), 399-403. DOI: 10.1188/08.CJON.399-403

Tan, J. and Payton, F.C. (2010). Adaptive Health Management Information Systems: Concepts, Cases, & Practical Applications, Third Edition. Sudbury, MA: Jones & Bartlett Learning.

Torsvik, M. & Hedlund, M. (2008). Cultural encounters in reflective dialogue about nursing care: a qualitative study. Journal of Advanced Nursing 63(4), 389–396. doi: 10.1111/j.1365-2648.2008.04723.x

Twibell, R.S. et al. (2010). Nurses’ Perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. American Journal of Critical Care, 17(2), 101-102.