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Certification Culture in the ICU

Critical-care nurses in the Southeast promote value of CCRN credential

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When Heather Maude, RN, CCRN, assistant nurse manager in the Michael P. Fisher Cardiac Intensive Care Unit (CICU) at Children's Healthcare of Atlanta, came to Georgia in 2002 from a large medical center in New York City, she was surprised to learn only two of her colleagues were certified in pediatric critical care nursing.

CERTIFIED & PROUD: Critical-care nurses pose in front of the "certification wall" that celebrates their accomplishments earning the CCRN credential at Children's Healthcare of Atlanta (photo courtesy Children's Healthcare of Atlanta)

"I started educating my co-workers about [the American Association of Critical-Care Nurses] and talking about the value of certification," she said. "In 2004, I attended AACN's National Teaching Institute and came back with a lot of ideas about creating a culture of certification. I met with my nurse manager, who told me to go ahead with the ideas. And then it hit me: what have I gotten myself into?"

Barriers to Certification

Maude recruited a core group of critical care nurses who were interested in obtaining certification and put together a 1-day review course.

"Some of those first nurses became instructors for subsequent review courses, which was exciting," she said. "We were able to help a few nurses get certified every year, but weren't seeing the participation we wanted. In talking with my colleagues, I found fear was a major barrier and financial concerns created a secondary barrier."

Maude and her colleagues devised an innovative two-pronged approach to those barriers.

"In 2008, we established a sponsorship program to support nurses who want to pursue their CCRN certification," she explained. "The hospital pays for their certification exam up front, the nurse signs a commitment to test, and we offer the nurse an opportunity to be connected with a CCRN-certified mentor who can support them."

Nurses seeking certification can borrow materials provided by the CCRN Education Council at Children's, including audio CDs of the certification review course, resource books, and sample test questions. Over the past 5 years, the number of CCRNs at Children's at Egleston has increased from 2 to 34.

"It's a difficult exam, and the AACN Web site says the pass rate is about 70 percent. We're proud that 85 percent of our nurses pass it," Maude said. "Many of our new grads are already asking about taking the exam, so we know we've created a culture that encourages certification."

Working Together

CERTIFICATION STARS: Certified critical-care nurses at Shands at the University of Florida include, from left, Marcia Kent, BSN, RN, CCRN, Lynne Mahaffey, RN, CCRN, Thanh Ngo, RN, CCRN, Scott Broschay BSN, RN, CCRN, Wendy Edmonds, JD, BA, RN, CCRN, and Erica Grek, RN, CCRN. (photo courtesy Lynne Mahaffey)

Lynne Mahaffey, RN, CCRN, a staff nurse in the CICU at Shands at the University of Florida in Gainesville, is proud to be one of the 22 CCRNs nurses at her hospital who joined together to overcome barriers to certification.

"That's 25 percent of our staff, and our new nurses are already asking when the next review course is, how tough the certification exam is, and what they can do to get ready for certification," she said.

The first time Shands nurses took the CCRN exam, 17 of them passed and their colleagues threw them a celebratory party.

"It was the enthusiasm of our core nurses about certification that started our move toward a culture of certification," Mahaffey said. "And our journey to earn a Beacon Award for Critical Care Excellence from AACN kept us on the right path. Certified staff members sharing resources and advice for others interested in taking the exam is also vital to our unit's success. It is common for study groups to meet outside of work to address the CCRN challenges in the clinical environment."

Shared Governance

Nancy Navarra, BSN, RN, CCRN, a clinical nurse IV in the neonatal ICU at Duke University Hospital, Durham, NC, believes shared governance can play an important role in creating a culture that embraces specialty certification.

"Back in 2003, there were four of us who wanted to increase the number of certified nurses at the hospital," she recalled. "We approached our chief nursing officer, Mary Ann Fuchs, [MSN, RN], and she gave us some wonderful guidance. She suggested we create a certification committee and use the Nurse Governance Council as a sounding board, so that's what we did."

Navarra put out a call to certification ambassadors from nursing specialty organizations working at Duke.

"We encouraged [them] to be creative in promoting awareness of the benefits of certification," she noted. "Nurses can be competitive at times, so we soon had certification boards, certification manuals, excellence boards showcasing certified nurses, and plaques. We use our nursing newsletter to share these great ideas."

A 2004 presentation to the nurse manager group at Duke brought middle managers onboard.

"[We talked] about the benefits of certification, using the CCRN process as an example," Navarra said. "We explained that activities like precepting [and] teaching a class can earn nurses Continuing Education Recognition Points to use toward recertification. We let them know that the more certified nurses they have on their units, the more nurses they'll find invested in activities that benefits patients, families, the nursing unit, and the organization."

The nursing community at Duke Health Systems found the message so compelling that the number of certified nurses has grown from 100 in 2003 to 600 and counting 7 years later.

"There's always someone on our unit studying for the exam, or preparing for recertification," Navarra said. "In 2006, we were awarded Magnet status, and certification certainly helped us achieve that distinction. And we've expanded beyond our own hospital to include Durham Regional Medical Center and Duke Raleigh Hospital as well."


Newly certified nurses bask in recognition from their leaders and colleagues. Irene Alexaitis, MSN, RN, vice president of nursing and patient care services at Shands, extends personal congratulations to nurses who earn their CCRN.

"Our annual evaluation system is linked to pay for performance," Mahaffey explained. "Certification, committee memberships, committee chairmanships, and other professional development activities help nurses achieve a higher score and earn higher salaries."

CCRN-certified nurses are prominently featured on a very special Wall of Honor with plaques showing their names, pictures, and certifications. "Doctors, other staff members, families, and visitors see those plaques, look for specific nurses, and comment positively about their achievements," Mahaffey said.

Navarra and her colleagues especially appreciate the recognition they receive from patients and family members.

"Patients have caring nurses who show a sense of pride in becoming certified and display their credential on their badges," she said. "They see that their nurses are well-invested in their profession and, in turn, their patients as they pursue more knowledge and skills to become certified in their fields."

Boosting Professional Growth

Many of the CCRNs at Shands have gained so much clinical confidence that they've emerged as "drivers" for the "Good to Great" unit-based performance improvement teams.

"They've tackled challenges including ventilator-associated pneumonia, bloodstream infections, urinary tract infections, pressure ulcer prevention and patient satisfaction," Mahaffey reported. "Nursing satisfaction and staff retention numbers are way up, and performance measures are outstanding."

Sandy Keefe is a frequent contributor to ADVANCE.

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