7

Taking the Temperature: Stakeholder Reactions and Suggestions

On the second day of the workshop, participants broke into working groups that focused on high-priority questions and topics within the following categories:

• 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; and
• Stakeholder perspectives, communication, and outreach.

Each breakout group was led by a planning committee member, who presented the group’s take-away points in the subsequent plenary session. These plenary presentations are summarized in this chapter, and should not be interpreted as the position of individual presenters or participants.

USING THE FRAMEWORK TO DEVELOP RESEARCH PRIORITIES TO ADVANCE NURSING CREDENTIALING

Presenters: Jack Needleman and Robert Dittus

This workgroup first considered what changes to the Expanded Conceptual Model for nursing credentialing research might be necessary (see Figure 2-2). The discussion focused on a number of points and missing elements included in Box 7-1.

In addition, the breakout group discussed the importance of considering whether voluntary certification would create a different framework and array of boxes and interactions than would mandatory credentialing. The breakout group further discussed emergent research priorities in nurse credentialing, emphasizing the following (not in priority order):

• Standardizing definitions of variables across systems and specialties, including current certification status;
• Identifying and measuring relevant confounding variables with validity, reliability, and efficiency;
• Incorporating social determinants of health in electronic health records (EHRs);
• Understanding the relationships among credentials, evidence-based practice, and competency at the individual, team, and organizational levels through understanding causal pathways;
• Determining the impact of credentialing on clinical outcomes (after resolution of other data and measurement challenges);
• Considering the need to be alert to possible unintended consequences;

• Establishing the business case to obtain organizational buy-in, taking into account changing value propositions as health care financing models evolve;
• Accounting for the influence of credentials in team-based practice; and
• Examining the impact of credentials on shaping future practice models.

In the discussion, workshop participants highlighted the need for the “model of care” to account for not just traditional outpatient care, but also community and person-centered care; not just acute care, but also health promotion and disease prevention; and not just individual care, but also group- or population-level services. These broader conceptualizations of what “health care” is involve many more professionals and “hand-offs.”

Finally, the breakout group cautioned against making the model so detailed that it is not useful and striking a good balance between clarity and completeness. Ultimately, conceptual clarity about the purposes for the model may guide those decisions, and different levels of detail will be needed for different purposes.

IMPROVING RESEARCH METHODOLOGIES

Presenter: Joanne Spetz

Spetz began with the question “What are the most important knowledge gaps?” The answer has implications for both the research methods and requisite data. In its discussions, the group identified five key questions that researchers should target:

1. What additional descriptive information about nursing credentialing and certification can be developed, including how many people are certified, what certifications do they have, and how are certifications distributed?
2. What is the value of a credential to an individual nurse?
3. What is the economic value to the organization for employing credentialed nurses?
4. Does certification improve nurses’ ability to implement evidence-based practices?
5. Which credentials matter for which outcomes?

Many members of the breakout group suggested that gaps in research methodologies are not the underlying problem. Big data analytic methods, translational research methods, qualitative methods, and a variety of analytic techniques from econometrics, epidemiology, biostatistics, and other fields are already available. The real problem is insufficient and inadequate data to answer the priority questions, explained Spetz. To overcome these problems, the group highlighted the need for:

• A common data model and a standardized method for data collection across human resource systems, state boards, and other organizations that would allow data to be merged. This process might start by a thorough review of what data are already being collected.
• Collection of minimum data set elements by state boards of nursing in their re-licensure surveys, which presupposes a more streamlined system than at present. This might be accomplished through collaboration with the National Forum of State Nursing Workforce Centers (which makes recommendations to state boards on minimum data set requirements) and with the Bureau of Health Workforce within the U.S. Health Resources and Services Administration. Technical assistance might be available through the National Center for Health Workforce Analysis to sort out some of the interprofessional data challenges.
• The addition of credentialing information to employers’ human resource databases, assuming existing databases can accommodate this information.
• Greater researcher access to existing (and new) data through public use datasets, using de-identified data, if necessary, from state boards of nursing, as an example.
• Standardized, organization-specific data on patient outcomes like that from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey or that may become increasingly available through electronic data systems.

With these kinds of data available, nursing researchers could unravel some questions about the relative importance of nurse, patient, and organizational factors affecting outcomes of interest to all stakeholders. Stakeholders who would benefit from credentialing, including state boards of nursing, should be involved in prioritizing research questions. Stakeholders who can help resolve data shortfalls (e.g., EHRs vendors,

human resources professionals, state boards, employers, nursing informatics experts, and others) should be involved in resolving those challenges.

SHORT- AND LONG-TERM STRATEGIES TO ENCOURAGE ACTIVITIES RELATED TO NURSING CREDENTIALING RESEARCH

Presenter: Kenneth W. Kizer

The breakout group agreed that enough evidence exists to pursue research in nursing credentialing, with the caveats that the quality and quantity of evidence related to individual credentialing and its link to outcomes is not as strong as that for organizational credentialing, began Kizer. Evidence is stronger with respect to mandatory as opposed to voluntary credentialing.

The breakout group recognized that some early actions are needed to pave the way for longer-term activities. Many of these actions were identified in earlier breakout group reports. This group noted the need to clearly identify priorities for research and establish conceptual links between priorities and the data that support them. Kizer noted that priorities—and the related data—will be fluid, changing over time. A good example is how cancer registries are being used now for different purposes than when they were originally designed as the demand for data relevant to quality improvement became a high priority.

Beyond that the group chose not to divide its list of goals into precise time frames. Instead, the group described seven goals, with the first four being the most time sensitive:

1. Getting the data house and information management tools in order, including organizing, collating, consolidating, and establishing coherence within nursing-relevant data scattered throughout the health system;
2. Once existing data have been assessed, identifying data gaps and strategies to fill them, along with consideration of the information management tools (e.g., EHRs, health information exchanges, registries) useful going forward, and refining the data resources over time;

3. Developing and implementing a strategic communications plan, including a consumer advocacy component, to increase understanding of how credentialing relates to patient care;
4. Considering a range of possible funders for this effort—philanthropy, government, professional organizations, large integrated delivery systems, or others—and make an effective case for these investments;
5. Building research capacity and infrastructure among the nurse credentialing organizations to promote consistent research over time, and endowed professorships might provide continuity within academic institutions;
6. Identifying which research methods appear better able to answer the most pressing questions—a task that cannot be done until a sufficient number of studies have been done to enable comparisons; and
7. Although the approach is controversial, using mandates—such as California’s required nurse staffing ratios—to stimulate research in related areas.

In response to a question about priority setting, Kizer said the breakout group considered whether the entity that articulates the priorities should be independent from the nursing enterprise, in order to avoid any real or perceived conflict of interest. That entity would need broad stakeholder input, including from the nursing community, he continued. Patients would need to be informed appropriately about the issues to meaningfully engage in the process.

STAKEHOLDER PERSPECTIVES, COMMUNICATION, AND OUTREACH

Presenter: Linda Burnes Bolton

To better understand the type of information that is important in credentialing research, it is important to identify and engage relevant stakeholder groups. To engage in discussions about credentialing research in nursing, the final breakout group presentation began with a review of important stakeholders, such as:

• the full range of payers, who may be interested in identifying factors that improve health outcomes and patient care for their beneficiaries;
• employers across settings, who must make decisions about returns on investment when determining whether to offer incentives to promote nursing;
• new nurses, who must transition from education in school to continuous learning across their careers;
• the National Council of State Boards of Nursing, which can stimulate interest in credentialing through licensure and relicensure requirements;
• risk managers, who are interested in reducing risks associated with adverse outcomes through more competent staff and adherence to evidence-based practice;
• nursing faculty;
• academic institutions;
• accrediting and regulatory agencies; and
• patients and families.

Second, the group discussed strategies to engage these different stakeholder groups. The group suggested that impartial, objective organizations could develop convening activities to educate stakeholders about topics related to credentialing research and to engage stakeholders in a discussion about the perceived value of a certified nursing workforce and high priority research questions. Among the breakout group’s other ideas were to:

• develop a broad-based promotional campaign aimed at informing the public about the value of having a certified nurse;
• create a standardized taxonomy for certification because nurses themselves may be confused about whether they are “certified” in the way meant by the professional organizations at the meeting;
• engage risk managers specifically with respect to the need for research, and if research validates the importance of certification, what that importance is; and
• develop transition-to-practice programs for new nurses that culminate in obtaining certification.

The breakout group’s proposed campaign for the public would emphasize the value of credentialing, rather than credentialing research. It might be useful to look for common quality- or safety-related threads that run through all certification programs, added Maureen Cahill.

LOOKING AHEAD—ESTABLISHING A COMMON VISION FOR FUTURE DIRECTIONS AND RESOURCES NEEDS IN NURSING CREDENTIALING RESEARCH

The workshop concluded with seven panelists describing some of the overarching messages and ideas generated during the workshop. Jack Needleman began by reiterating the need for data that are more structured, more accessible, and less expensive. Prior studies have used relatively high-level data sources, one-off data systems, or special data collections, and these sources are not sufficient for the agenda proposed in the workshop. On one hand, they are not fine-grained enough, and on the other, many are too small. The future will include mining patients’ EHRs and linking them to health care personnel databases that include information on credentials. The certification organizations are “absolutely critical” to data standardization, Needleman said, and should develop and employ a common data set for each certified nurse.

Robin Newhouse suggested development of standard metrics with clear conceptual and operational definitions at both the unit and organizational levels to establish the relationship of the “nurse dose”¹ and nurse and patient outcomes. She suggested that a technical expert panel (including a psychometrician, an informatics expert, and a database expert) could develop this metric, which should be vetted by numerous stakeholders (e.g., the National Quality Forum to encourage widespread diffusion) and pilot tested.

Robert Dittus suggested integrating nursing certification as a theme for researchers with multiple different agendas—health outcomes, patient care, process management—as a way to move forward more quickly. Examples of initiatives already under way that might be leveraged in this manner would include the Patient-Centered Outcomes Research Institute (PCORI) and its 11 Clinical Data Research Networks (PCORI, 2014); foundations and other funding agencies’ programs addressing health care quality; the Center for Medicare & Medicaid Innovation, with its focus

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¹Brooten and Youngblut (2006) provide a review of the concept of “nurse dose.”

on care coordination and population health; and large health care delivery systems’ ongoing research projects. Linda Burnes Bolton also focused on the end goals, suggesting efforts to determine whether and how credentialing contributes to the overall “social good” of helping people obtain and sustain health. She also believed that doing so would establish the usefulness of credentialing research.

Karen Drenkard suggested prioritizing credentialing research that would be useful to individuals and organizations attempting to determine the return on investments. Although some organizations may encourage credentialing “because it seems the right thing to do,” she said, research will have to justify those investments in the long run. Understanding the links among certification, practice, and outcomes is essential to any value-based reimbursement model, she said. Similarly, Ken Kizer suggested that, if nursing credentialing and nursing credentialing research are to be viable in the long term, they must “quantifiably demonstrate value both to health and to health care.” These are not necessarily the same thing, he said, and they must demonstrate these effects “in ways that are important and meaningful.” In the short term, Kizer continued, credentialing research could focus on potential contributions to integrated care.

Lynne Grief emphasized the issue of team credentialing, suggesting that teams of credentialed individuals could identify the best evidence and apply it consistently in practice to achieve the best results for patients.

In closing, Bobbie Berkowitz, the planning committee chair, thanked the speakers, planning committee members, and standing committee members for setting the stage on day one, which lead to fruitful and informative discussions on the last day.

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