Certification Research

Value of Specialty Nursing Certification Resources

A certification program is the formal process by which a certifying agency validates a nurse’s knowledge, skills, and abilities in a defined role and clinical area of practice. For the Competency and Credentialing Institute that clinical area of practice is perioperative nursing. The certification process allows the healthcare consumer to easily recognize the achievement, expertise and clinical judgment demonstrated in nurses who have earned a credential. Those nurses holding the certification possess specialized education, experience in a specialty area and have successfully passed a rigorous qualifying exam. There is also documented evidence of the benefits of certification for the individual nurse and the employer.

A number of resources on the subject of certification to include technical reports and peer-reviewed journal articles are presented in the sections of this webpage as a resource for nurses who desire more information on the subject. For students and researchers this webpage will serve as a brief introduction on the subject and provide sources for additional materials for more in depth study.


American Board of Nursing Specialties Bibliography

The American Board of Nursing Specialties (ABNS) provides an extensive bibliography of published sources on nursing certification including value of certification, specialty certification and patient outcome studies. This bibliography is updated annually and represents the most comprehensive source of articles on nursing certification.

Institute for Credentialing Excellence Bibliography

This link will access a webpage maintained by the Institute for Credentialing Excellence. On this page there are additional links to a number of websites with certification and test preparation material.

Interdisciplinary Nursing Quality Research Initiative (INQRI)

The Interdisciplinary Nursing Quality Research Initiative (INQRI) is strategically focused on supporting interdisciplinary teams that proposed diverse, innovative research initiatives designed to establish the link between nursing and high-quality. INQRI's primary goal is to generate, disseminate and translate research to understand how nurses contribute to and can improve the quality of patient care. The INQRI website has information on research studies, articles, reports, and meetings related to nurses’ impact on safe patient care.

ANCC Magnet Program

The ANCC Magnet program has identified the forces of magnetism in hospitals that exemplify nursing excellence. Professional certification is a specified element of Force 14: Professional Development. The CNOR and CRNFA credentials are Category A certifications.

ABNS White Paper on the Value of Certification

A link to the white paper prepared by the American Board of Nursing Specialty regarding their national level survey of 11,427 nurses. This national study broke new ground by surveying a sample of certified nurses, noncertified nurses and a sub-sample of nurse managers across 20 different specialty nursing certification organizations. The study also sought to address a variety of ABNS member-generated research priorities by exploring nurse managers’ perceptions of the value of certification, challenges and barriers to certification, benefits and rewards to nurses who are certified, the impact of certification on lost workdays, and the impact of certification on nurse retention.

Competency Assessment Resources

Continued Professional Competence and Portfolios
Byrne M, Delarose T, King CA, Leske J, Sapnas, KG & Schroeter K
Journal of Trauma Nursing: January/March (2007) 14(1) pp. 24-31


It is traditionally assumed that licensure of healthcare professionals means that they are minimally competent. Many nursing specialty organizations offer examinations and other processes for certification, suggesting that certification is associated with continued competency. Can standardized examination for certification and continuing education for recertification ensure continued competency? Continuing education and testing provide a limited picture of an individual's knowledge and/or skill acquisition in a limited area at one point in time. However, portfolios promote critical thinking, self-assessment, and individual accountability. A portfolio is a portable mechanism for evaluating competencies that may otherwise be difficult to assess. This article summarizes some of the literature addressing portfolios, including aspects of portfolio development process, the value of portfolios versus continuing education for competency assessment, evidence associated with portfolio usage, and suggestions for organizing nursing portfolios.

The professional portfolio: an evidence-based assessment method
Byrne M, Schroeter K, Carter S. & Mower J
J Contin Educ Nurs. (2009) December 40(12) pp. 545-52


Competency assessment is critical for a myriad of disciplines, including medicine, law, education, and nursing. Many nurse managers and educators are responsible for nursing competency assessment, and assessment results are often used for annual reviews, promotions, and satisfying accrediting agencies' requirements. Credentialing bodies continually seek methods to measure and document the continuing competence of licensees or certificants. Many methods and frameworks for continued competency assessment exist. The portfolio process is one method to validate personal and professional accomplishments in an interactive, multidimensional manner. This article illustrates how portfolios can be used to assess competence. One specialty nursing certification board's process of creating an evidence-based portfolio for recertification or reactivation of a credential is used as an example. The theoretical background, development process, implementation, and future implications may serve as a template for other organizations in developing their own portfolio models.

Assessing continued competency through simulation: A call for stringent action
Decker S, Utterback VA, Thomas MB, Mitchell M, & Sportsman S
Nurs Educ Perspect. (2011) March-April 32(2) pp. 120-5.


This article proposes that simulation has potential as a method to validate critical and reflective thinking skills and continued competency of registered nurses. The authors recognize the challenges and benefits for using simulation in assessing competency. Furthermore, the authors stress that the potential use of simulation in competency testing cannot be achieved until educators and researchers acquire the specific knowledge and skills to make informed decisions and recommend policy.

Portfolios: Implications for Perioperative Education, Evaluation & Competency Assessment
Byrne M and Schroeter K
MS PowerPoint presentation presented at the 52nd Annual AORN Congress, Orlando, Florida, March 2007


This MS PowerPoint presentation explains the use a professional portfolio in a nursing certification program. The detail is given of how the Competency and Credentialing Institute initiated a professional portfolio process for recertification and reactivation of the CNOR credential. The twelve Professional Activities that comprise the portfolio are summarized with perioperative-specific examples provided for each activity. This presentation puts the professional portfolio process within the larger context of calls for increased personal accountability in the American healthcare system and also frames the portfolio process as a means to address continuing competency requirements.

The CCI Professional Portfolio: An Evidence Based Tool for CNOR Recertification or Reactivation
Carter S
MS PowerPoint presentation presented at the Citizen Advocacy Center Continued Competence Conference, May 2008.

The link below is to a short MS PowerPoint presentation on the professional portfolio process utilized by the Competency and Credentialing Institute to support the CNOR credential. This portfolio process being one of the two methods that can be used to reactivate a lapsed credential. The presentation details the submission process to include the 12 professional activities which are the core of the program, the reflection process and the process by which the portfolios are evaluated.

CCI Resources

The Future of Learning: Building a Bridge between Competency and Patient Safety
Byrne M,
Competency & Credentialing Institute Think Tank Pre-Event White Paper (2005).

This link will take the reader to a white paper which was done by the Competency and Credentialing Institute prior to the convening a think tank on this subject. This paper explores the link between patient safety in American healthcare and the influence of healthcare provider competency. A summary of the current literature on both subjects is provided along with a discussion of cutting edge methods used in competency assessment. An extensive reference list is provided along with a list of related websites.

The Future of Learning, Building a Bridge Between Competency and Patient Safety
Moss, R
Competency & Credentialing Institute Think Tank Post-Event White Paper (2005).

Primary Conclusions

The first topics addressed by the group were the driving forces and trends for the next ten years to 2015. It was agreed that technological advancements will continue at an unprecedented pace, which will directly affect the delivery of health care. One of the advantages of technology is that it can enhance human performance to the extent that the human plus the technology is more powerful than either alone (Norman, 1993). Technology, however, also can create new demands on practitioners (IOM, 2000). For example, a new piece of equipment may provide more precise measurements, but may also demand better precision from the operator for the equipment to work properly (Cook & Woods, 1994). Technology in the health care system also must be recognized as a “member” of the work team (IOM, 2000). When technology shifts workloads and work responsibilities, it also shifts system dynamics. For example, technology may enable a task to be completed by fewer people. This ultimately affects the distributed nature of the job in which tasks are shared among several people and may influence the ability to discover and recover from errors (Norman, 1993). The types of medical equipment and devices used by our diverse population will change health care. As more care shifts to ambulatory and in-home settings, the use of medical technology by non-health professionals will take on greater significance (IOM, 2000).

Continued Competence Leadership Forum: From Pieces to Policy
Byrne M and Waters L
Competency & Credentialing Institute Think Tank Post-Event White Paper (2007).

The Competency & Credentialing Institute (CCI) convened scholars and thought leaders in healthcare competency from across North America at a Think Tank September 16 – 19, 2007, to explore how nursing can collaborate to develop a framework for continuing competence driven by the principles of patient safety. The 2007 forum built on the initial work of a multidisciplinary Think Tank held in 2005. The 2007 participants represented a wide spectrum of perspectives. An expected outcome of this discussion was documentation of current thinking and issues surrounding the topics of continuing competence and patient safety. This active engagement of scholars and thought leaders can be viewed as participatory action research, which is intended to move theory to action for communities addressing complex challenges. This White paper communicates the collective understanding from the CCI 2007 Think Tank of how nursing can ensure ongoing competence development that enhances both the profession and patient care.

Competence Literature Review
Schroeter K

The literature on the concept of competence is myriad and encompasses many related descriptors. For the purposes of this review the concept of competence will be addressed in the following categories: competence, lack of competence, and the factors that affect/impact on competence. However, when discussing categories of competence in the health care and nursing literature, further divisions based on nursing role can be analyzed, i.e. competence of staff nurses, nurse administrators, educators and other specific specialty roles (e.g. perioperative nurses). In the 1970’s, the realm of nursing education and preparation for practice began a shift to focus on the concept of competence-based education. The educators at Alverno College in Wisconsin instituted the first competency based baccalaureate nursing education program. However, even though this competency-based approach to education has been evident in nursing for the past 30 years, little consensus exists regarding the definition and application of competence in nursing. This review synthesizes a significant amount of literature related to the definitions and descriptions of “competence” as a concept inherent to nursing practice. Subsequent to a focused review of literature, issues inherent to the definition and utilization of the concept of nursing competence are discussed.

Certification: What is the value?
Competency and Credentialing Institute
OR Manager, September 2010 26(9) pp.1-3

This article provides an overview of nursing certification. The rationale for support of nursing certification is provided from the perspective of a variety of stakeholders to include a board member of the Competency and Credentialing Institute, a director of surgical services and a surgical services educator. The article summarizes the recent literature on the topic and explains what is known, and not known, regarding the relationship between nursing certification and patient outcomes.

Current Literature Regarding Certification

Results of the 2014 AORN salary and compensation survey.
Bacon, D R, & Stewart, K A (2014).
AORN Journal. 100(6). pp. 570-585.


AORN conducted its 12th annual compensation survey for perioperative nurses in June and July 2014. A multiple regression model was used to examine how a number of variables, including job title, education level, certification, experience, and geographic region, affect nurse compensation. Comparisons between the data from 2014 and data from previous years are presented. The effects of other forms of compensation (eg, on-call compensation, overtime, bonuses, shift differentials) on base compensation rates also are examined. Additional analyses explore the effect of the economic downturn on the perioperative work environment.

A sample of 3,437 nurses responded to this version of the annual survey. Although not a random sample of perioperative nurses it was found that those holding the CNOR certification earned $2,200 more and those holding the BC certification earned $6,900 more than other nurse respondents. Other statistically significant influences on wages included job title, hospital type and education levels.

The Relationship between direct-care RN specialty certification and surgical patient outcomes.
Boyle, DK, Cramer, E, Potter, C, Gatua, MW and Stobinski, JX (2014).
AORN Journal (100) 5, pp. 511–528.


Specialty certification enhances patient safety in health care by validating that practice is consistent with standards of excellence. The purpose of this research was to explore the relationship between direct-care, specialty-certified nurses employed in perioperative units, surgical intensive care units (SICUs), and surgical units and nursing-sensitive patient outcomes in SICUs and surgical units. Lower rates of central-line–associated bloodstream infections in SICUs were significantly associated with higher rates of CPAN (certified postanesthesia nurse) (β = -0.09, P = .05) and CNOR/CRNFA (certified nurse operating room/certified RN first assistant) (β = -0.17, P = .00) certifications in perioperative units. Unexpectedly, higher rates of CNOR/CRNFA certification in perioperative units were associated with higher rates of hospital-acquired pressure ulcers (β = 0.08, P = .03) and unit-acquired pressure ulcers (β = 0.13, P = .00), possibly because of a higher risk of pressure ulcers in the patient population. Additional research is needed to clarify this relationship. These findings lend credence to perioperative, SICU, and surgical nurses participating in lifelong learning and continuous professional development, including achievement of specialty certification.

Certification and Clinical Ladder as the Impetus for Professional Development
Watts M D
Crit Care Nurs Q. (2010) 33(1); pp. 52–59


With today’s healthcare challenges of nursing shortages and financial instability, it is imperative that healthcare organizations retain clinically competent nurses at the bedside. Professional development and recognition are key motivators to increase nursing job satisfaction, thus reducing shortages and turnover. Implementation of specialty certification and clinical advancement programs is of benefit to the public, employers, and nurses alike. Clinical ladder and Magnet recognition are often the impetus for specialty nursing certification in healthcare institutions. Clinical ladder history, purpose, models, perceptions, and satisfiers are discussed. Certification statistics, types, impetus, benefits, incentives, and barriers are highlighted, as well as a facility’s innovative strategy to increase specialty certification. Certification and clinical ladder programs demonstrate commitment of healthcare organizations and nursing staff to provide high-quality care and professional nursing development, an investment that hospitals cannot afford to overlook.

Structural Empowerment: The Magnet Model applied to Perioperative Nursing
Schroeter, K
AORN Journal (2010) 92(2); pp. 220-223.


Nursing excellence, the primary focus of the Magnet™ program, flourishes in an environment in which nurses can freely practice to the best of their abilities. One component of the Magnet model is structural empowerment, which encompasses five of the 14 Forces of Magnetism including organizational structure, personnel policies and procedures, community and the health care organization, the image of nursing, and professional development.

Included in the concept of structural empowerment are the specific components inherent to the empowerment of nurses in the organization. Empowered nurses are more apt to practice skills such as decision making, problem solving, care provision, and changing of care as needed. The concept of empowerment is intrinsic to nursing practice because nurses are licensed to provide care; with licensure comes associated power, responsibility, and accountability. The integral structural conditions necessary for empowerment are evident in the Forces of Magnetism in the structural empowerment section of the Magnet model.

This author discusses the link between the five Forces of Magnetism and the concept of structural empowerment. Schroeter elaborates on the practical considerations which must be considered when attempting to actualize these five Forces of Magnetism in the perioperative setting.

Nursing Specialty Certification and Nursing-Sensitive Patient Outcomes in the Intensive Care Unit
Krapohl G, Manojlovich M, Redman R & Zhang L
Am J Crit Care November (2010) 19(60) pp. 490-498


To the public and to individual nurses, certification usually means expert, high-quality, competent nursing care. Little research, however, has yielded results that support, or refute, any differences in clinical practice between certified and noncertified nurses. The objective of this study was to determine whether the proportion of certified nurses on a unit is associated with the rate of nurse-sensitive patient outcomes. A non-experimental, correlational, descriptive design was used to anonymously survey 866 nurses working in 25 intensive care units in Southeast Michigan. The Conditions for Work Effectiveness Questionnaire-II was used to measure workplace empowerment, and an additional question was asked about certification status. Outcome data were simultaneously collected on 3 nurse-sensitive patient outcomes: (1) rate of central line catheter-associated blood stream infection, (2) rate of ventilator-associated pneumonia, and (3) prevalence of pressure ulcers. Data were aggregated and analyzed at the unit level. No significant relationship was found between the proportion of certified nurses on a unit and patients’ outcomes. The association between nurses’ perception of overall work-place empowerment and certification, however, was positive and statistically significant (r=.397, P=.05). Although a link between certification and nurse-sensitive outcomes was not established, the association between workplace empowerment and the proportion of certified nurses on a unit underscores the importance of organizational factors in the promotion of nursing certification.

The Value of Certification
Kaplow R
AACN Advanced Critical Care (2011) 22(1) pp. 25–32

Certification is defined in the nursing literature in several ways; no one consistent definition of certification exists. Nursing specialty certification programs are intended for consumer protection. Certification protects the public by enabling consumers to identify competent people more readily. However, benefits for stakeholders other than patients and families are also described in the literature. This article describes the value of specialty certification from the perspective of the patient and family, nurse, and employer.

Nurse Specialty Certification, Inpatient Mortality, and Failure to Rescue
Kendall-Gallagher D, Aiken LH, Sloane D M & Cimiotti J P
J Nurs Scholarsh. (2011) June 43(2) pp. 188–194.


To determine if hospital proportion of staff nurses with specialty certification is associated with risk-adjusted inpatient 30-day mortality and failure to rescue (deaths in surgical inpatients following a major complication). Secondary analysis of risk-adjusted adult general, orthopedic, and vascular surgical inpatients discharged during 2005–2006 (n = 1,283,241) from 652 nonfederal hospitals controlling for state, hospital, patient, and nursing characteristics by linking outcomes, administrative, and nurse survey data (n = 28,598). Nurse data, categorized by education and certification status, were aggregated to the hospital level. Logistic regression models were used to estimate effects of specialty certification and other nursing characteristics on mortality and failure to rescue. Hospital proportion of baccalaureate and certified baccalaureate staff nurses were associated with mortality and failure to rescue; no effect of specialization was seen in the absence of baccalaureate education. A 10% increase in hospital proportion of baccalaureate and certified baccalaureate staff nurses, respectively, decreased the odds of adjusted inpatient 30-day mortality by 6% and 2%; results for failure to rescue were identical. Nurse specialty certification is associated with better patient outcomes; effect on mortality and failure to rescue in general surgery patients is contingent upon baccalaureate education. Investment in a baccalaureate-educated workforce and specialty certification has the potential to improve the quality of care.

Lower Mortality In Magnet Hospitals
McHugh MD, Kelly LA, Smith HL, Wu ES, Vanak JM & Aiken LH
Med Care. 2013 May 51(5):382-8


Although there is evidence that hospitals recognized for nursing excellence--Magnet hospitals--are successful in attracting and retaining nurses, it is uncertain whether Magnet recognition is associated with better patient outcomes than non-Magnets, and if so why.

OBJECTIVES: To determine whether Magnet hospitals have lower risk-adjusted mortality and failure-to-rescue compared with non-Magnet hospitals, and to determine the most likely explanations.

METHOD AND STUDY DESIGN: Analysis of linked patient, nurse, and hospital data on 56 Magnet and 508 non-Magnet hospitals. Logistic regression models were used to estimate differences in the odds of mortality and failure-to-rescue for surgical patients treated in Magnet versus non-Magnet hospitals, and to determine the extent to which differences in outcomes can be explained by nursing after accounting for patient and hospital differences.

RESULTS: Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor's degrees and specialty certification. These nursing factors explained much of the Magnet hospital effect on patient outcomes. However, patients treated in Magnet hospitals had 14% lower odds of mortality (odds ratio 0.86; 95% confidence interval, 0.76-0.98; P=0.02) and 12% lower odds of failure-to-rescue (odds ratio 0.88; 95% confidence interval, 0.77-1.01; P=0.07) while controlling for nursing factors as well as hospital and patient differences.

CONCLUSIONS: The lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.

Test Taking Strategies for CNOR Certification
Lamonte M
AORN Journal 85(4) (February 2007). pp. 315-332.


A perioperative nurse who desires to advance his or her career may want to consider becoming CNOR certified. Test questions on the CNOR examination are designed to measure a nurse's knowledge of basic facts about perioperative nursing or the application of that knowledge. This article provides suggestions for studying and preparing for the CNOR examination with sample test questions and test-taking strategies.

Current Literature on Nursing Professional Development

Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study.
Aiken, LH, Sloane, DM, Bruyneel, L, Van den Heede, K, Griffiths, P, Busse, R, Diomidous, M, Kinnunen, J, Kózka, M, Lesaffre, E, McHugh, MD, Moreno-Casbas, MT, Rafferty, AM, Schwendimann, R, Scott, PA, Tishelman, C, van Achterberg, T, Sermeus, W. (2014).
The Lancet. (383). pp. 1824-1830.


As a large component of labor expenses nurse staffing is a frequent target of cost cutting measures in healthcare. In a time of economic uncertainty and rapid change nurse staffing is often disproportionately affected in budget cuts. Aiken and her co-authors make the point that the effect of such staffing cuts should be reconsidered in light of the potential to adversely impact patient outcomes.

In this study of 300 European hospitals the variables of nurse staffing ratios and also nursing education levels were studied in relation to patient outcomes. Key findings were that, “Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.”(p. 1284). It was found that increase in the number of patients cared for by nurses raised the risk of patient mortality and that increases in nursing education levels to the baccalaureate degree level decreased this same risk. These findings may seem counterintuitive to hospital administrators but it does give pause to reconsider oft-used strategies regarding nurse staffing ratios.

Results of the 2014 AORN salary and compensation survey. 
Bacon, D R, & Stewart, K A (2014).
AORN Journal. 100(6). pp. 570-585.


AORN conducted its 12th annual compensation survey for perioperative nurses in June and July 2014. A multiple regression model was used to examine how a number of variables, including job title, education level, certification, experience, and geographic region, affect nurse compensation. Comparisons between the data from 2014 and data from previous years are presented. The effects of other forms of compensation (eg, on-call compensation, overtime, bonuses, shift differentials) on base compensation rates also are examined. Additional analyses explore the effect of the economic downturn on the perioperative work environment.


A sample of 3,437 nurses responded to this version of the annual survey. Although not a random sample of perioperative nurses it was found that those holding the CNOR certification earned $2,200 more and those holding the BC certification earned $6,900 more than other nurse respondents. Other statistically significant influences on wages included job title, hospital type and education levels.