The American Board of

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1 Professional Issues Medical-Surgical Nurses Perceived Value of Certification Study Mimi Haskins, Cynthia Nowicki Hnatiuk, and Linda H. Yoder The American Board of Nursing Specialties (ABNS) defines nursing certification as the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes (Niebuhr & Biel, 2007, p. 176). Certification validates superior knowledge of a specialty nursing area and implies continued high achievement through the process of recertification. Professional certification has been a measure of distinctive nursing practice since the 1970s, and it is a criterion for meeting the multiple standards within the American Nurses Credentialing Center s (ANCC) Magnet Recog - nition Program for excellence in nursing services (Shirey, 2005). In 2005, ABNS conducted research across 20 different specialty nursing certification organizations to validate nurses perceptions, values, and behaviors related to certification. Having just begun its certification program, the Medical-Surgical Nurs - ing Certification Board (MSNCB) was unable to participate in the original study. MSNCB recognizes the professionalism and expertise of medicalsurgical nurses, and grants the CMSRN credential (Certified Medical- Surgical Registered Nurse). This certification body is endorsed by the Academy of Medical-Surgical Nurses (AMSN), and its program is accredited by the Accreditation Board for Specialty Nursing Certification (ABSNC). Purpose In 2008, MSNCB received permission to use the Perceived Value of Certification Tool (PVCT) in its The Medical-Surgical Nursing Certification Board replicated a study to validate medical-surgical nurses perceptions, values, and behaviors related to specialty certification. Study results indicated both certified and non-certified medical-surgical nurses had positive perceptions of the value of certification. replication of the 2005 ABNS study. The intent of the MSNCB study was to assess medical-surgical nurses perceptions, values, and behaviors related to certification, and obtain data that would provide MSNCB with information related to the following topics: 1. Perceived value of certification by medical-surgical nurses 2. Perceived value of certification by medical-surgical nurses as compared to the ABNS study respondents 3. Impact of certification on lost workdays 4. Ongoing challenges to maintain interest and relevancy of certification 5. Impact of certification on retention of nurses 6. Benefits and rewards to certified nurses 7. Value of certified nurses as perceived by managers Review of the Literature Perceived Value of Certification Cary (2001) indicated research in the area of certification continues to be in its infancy. Authors have identified differences in perceptions of empowerment among certified and non-certified nurses (Piazza, Donahue, Dykes, Griffin, & Fitzpatrick, 2006); the significance of certification as an indicator for increased knowledge and experience a registered nurse can offer (Stromberg et al., 2005); and the preference of nurse managers to hire certified nurses (Ridge, 2008). A recent study found newly certified nurses who took the medical-surgical certification review course felt more confident and competent in their roles, with enhanced collaboration the result (Sayre, Wyant, & Karvonen, 2010). Gladfelter (2006) concluded the value of certification is in promot- Mimi Haskins, MS, RN, CMSRN, is the Value of Certification Research Project Coordinator; Director, Medical-Surgical Nursing Certification Board; and Nursing Staff Development Instructor, Roswell Park Cancer Institute, Buffalo, NY. Cynthia Nowicki Hnatiuk, EdD, RN, CAE, is Executive Director, Medical-Surgical Nursing Certification Board, and Vice President, Organizational Development, Anthony J. Jannetti, Inc., Pitman, NJ. Linda H. Yoder, PhD, MBA, RN, AOCN, FAAN, is Director, Academy of Medical-Surgical Nurses, and Associate Professor, Luci Baines Johnson Fellow in Nursing, University of Texas at Austin School of Nursing, Austin, TX. Acknowledgment: The authors wish to thank Guy P. Haskins, PhD, for his assistance with data analysis and interpretation; Melissa Biel, DPA, RN, for her consultation on the data collection methods and review of the article; and Noreen Dunn for her assistance with the initial survey and data collection. Also, thanks to the Academy of Medical-Surgical Nurses Research Committee for its valuable input. March-April 2011 Vol. 20/No. 2 71

2 Professional Issues ing continued excellence in professional care and is a clear indicator of commitment, not only to one s specialty, but also to one s personal and professional growth and dedication (p. 209). Piazza and co-authors (2006) discussed how attainment of certification denotes achievement and success, and results in the recognition of the nurse in the organization. Authors further stated, Certification can also increase a nurse s informal power on the nursing unit as it indicates knowledge and expertise in the specialty (p. 278). The perceived value of certification was well documented in the International Study of the Certified Nurse Workforce, in which a random sample of 19,452 nurses from 23 certifying organizations in the United States, Canada, and U.S. territories was polled (Cary, 2001). Results of the study provided initial evidence that certification may give nurses the means and opportunity to practice in a manner likely to improve outcomes (Cary, 2001, p. 49). It also initiated questions for further research related to confirmation of contributions to productivity, retention, and high-quality health care by the certified nurse workforce. The 2005 ABNS study, which the current study replicated, surveyed 11,000 certified and non-certified nurses as well as a subset of nurse managers across 20 nursing specialties. Using the PVCT, respondents reported a high level of agreement with respect to the value of certification, although certified respondents demonstrated a higher percentage of agreement with the value statements than non-certified nurses. These results also supported the primary benefits of certification, such as personal achievement, validation of knowledge, and access to a broad range of job opportunities. They also identified barriers to certification, including lack of professional recognition, lack of institutional support and reward, and cost issues related to testing and certification maintenance (Niebuhr & Biel, 2007). Benefits of Certification Research concerning specialty nursing certification clearly demonstrated both tangible and intangible benefits of certification. Certification validates a nurse s qualifications and advanced competence, and demonstrates his or her professional aspirations to improve the quality of patient care and delivery of services (Eisemon & Cline, 2006). In a study of certified and noncertified nurses, Piazza and colleagues (2006) found certified nurses had higher perceptions of empowerment than non-certified nurses. Furthermore, perceived benefits of certification have included recognition of expertise, financial incentives (especially higher salaries), increased potential for promotion, job security, and greater professional credibility through increased confidence in specialty skills and knowledge (Cary, 2001). Nurses also noted their overall improvement as practice professionals (Byrne, Valentine, & Carter, 2004). Additionally, nurses certified 5 years or less perceived certification was linked to fewer medical errors as well as increased job satisfaction and confidence (Cary, 2001). Finally, Gladfelter (2006) indicated certification validates recognition from peers, and increases career opportunities and professional satisfaction. Another benefit of certification is its effect on recruitment and retention of nurses, as well as increased interest in obtaining Magnet designation through the ANCC Magnet Recognition Program. According to Shirey (2005), promoting nursing certification is consistent with achieving high professional standards. As more hospital organizations aspire to achieve Magnet designation, certification in nursing takes on even greater significance. A recent review of the literature (Wade, 2009) regarding the perceived effects of specialty nurse certification indicated certification was positively associated with nurses perception of: (a) intrinsic value, (b) empowerment, (c) sense of collaboration with other health care team members, and (d) clinical nursing competence/expertise. Furthermore, Wade indicated certification has the potential to increase nurses retention as it validates and recognizes their skills and knowledge. In addition, certification was associated positively with nurses job satisfaction. Perceived Barriers to Certification In a study by Byrne and colleagues (2004) using the PVCT, the most frequently reported barriers to certification for nurses were the costs related to taking the exam and maintaining certification, lack of institutional support and reward, lack of time to prepare for the exam, and lack of study resources. Nurses who had been certified but let their credentials lapse offered the following reasons: lack of recognition, lack of compensation, cost of renewal fee, lack of time for continuing education, and personal circumstances. In a study by Sechrist, Valentine, and Berlin (2006), the PVCT again was used to determine the similarities and differences in perceived value of certification among three groups of perioperative nurses. As in the earlier study (Byrne et al., 2004), listed barriers to certification were related most often to extrinsic rewards. Survey Methods The survey tool used for this study consisted of the 18-item Perceived Value of Certification Tool developed by the Competency and Credentialing Institute (CCI, formerly Certification Board Perioperative Nursing), as well as questions developed by the ABNS Research Committee to focus on identified research priorities and obtain specific demographic information. The PVCT was demonstrated to have excellent reliability and validity. In a recent study of 2,323 certified and non-certified operating room nurses, internal consistency reliability (coefficient alpha) for the PVCT was Two factors, intrinsic and extrinsic values of certification, explained 59.2% of the variance, with all factor loadings at or above 0.58 (CCI, 2010). The PVCT incorporates 18 certification-related value statements, utilizing a five-point Likert scale (strongly agree, agree, disagree, strongly disagree, no opinion). The value statements are grouped or classified by two factors: intrinsic and extrinsic rewards for certifica- 72 March-April 2011 Vol. 20/No. 2

3 Medical-Surgical Nurses Perceived Value of Certification Study tion. Intrinsic rewards are motivators internal to an individual and linked to personal development and selfconcept values, while extrinsic rewards are external to an individual and defined by others (Niebuhr & Biel, 2007). The survey tool was reviewed by members of the AMSN Research Committee. Revisions, in the form of three additional questions, were made to the demographic information and the survey was formatted into a web-based survey. The questions were reviewed and approved by Melissa Biel, DPA, RN, a co-author of the original ABNS study. The survey and the web-based process were piloted by the MSNCB Board of Directors, comprised of registered nurses and one public member. Subsequent feedback, related to an issue with the web-based survey function from the pilot testers, was incorporated into the final revisions of the study instrument. The Medical-Surgical Nurses Perceived Value of Certification Study survey was formatted and provided via Internet technology. In May 2009, the survey link was ed to a random sample of certified and non-certified medical-surgical registered nurses, including a subset of nurse managers, from the AMSN and MSNCB databases. Institutional review board approval was not sought because this study did not meet the criteria for human subject research. Additionally, professional organizations may survey their members for educational purposes and report those results. Partici - pation in the study was voluntary and participants remained anonymous to the research team. Response Rates Of the 6,775 nurses in the sample, 1,748 responded (1,659 complete, 89 partial responses) and 491 s returned. The web-based survey tool utilized a link that allowed recipients to decline the survey; 20 declined to participate. Survey response rate was 26%. Demographic Characteristics The typical MSNCB survey respondent was a female (94.7%), Caucasian (75.4%), with an average of 17.3 years of nursing practice. The average respondent was age 46 (range 24-72). Staff nurse (31.8%) was the primary respondent category, followed by charge nurse/shift supervisor (16.5%), nurse educator (11.8%), nurse manager (8.9%), and advanced practice nurse (2.2%) cohorts (see Table 1 for further demographics related to typical survey respondents). Findings TABLE 1. Demographics of Survey Respondents Demographic % of MSNCB Respondents Highest academic degree held 41% BSN Primary work setting 88.7% Acute care hospital Certification voluntary for nursing practice 72.9% Percent of respondents holding the CMSRN 68.9% credential Annual income $50,000 - $89,000 70% The current study examined seven topics: 1. Perceived value of certification by medical-surgical nurses. Respons - es by both certified and non-certified nurses to survey statements indicated a high level of agreement with the value statements about certified practice, although a higher percentage of certified nurses reported agreement with the value statements than non-certified nurses. The one statement that received a low level of agreement by both groups of respondents was, Certification increases salary. To simplify describing the results, the participant responses of agree and strongly agree were grouped (see Table 2) in order of agreement within the intrinsic and extrinsic value statement categories. 2. Perceived value of certification by medical-surgical nurses compared to ABNS survey respondents. Results reflected a general level of positive agreement (strongly agree and agree) across all items for both MSNCB and ABNS response distributions (Niebuhr & Biel, 2007) (see Table 3). However, for the MSNCB Intrinsic Factor items, a higher level of positive outcome was evident for the following statements: Enhances personal confidence in clinical abilities, Indicates level of clinical competence, Provides evidence of accountability, and Enhances professional autonomy. For the Extrinsic Factor component of the PVCT, MSNCB results demonstrated a higher level of positive response for the following statements: Promotes recognition from employers, Increases consumer confidence, Increases salary. These results not only document the comparability of MSNCB and ABNS groups, but also indicate a very favorable extent of agreement across statements for both intrinsic and extrinsic factors for the MSNCB group. 3. Impact of certification on lost workdays. Survey respondents documented a range of days absent from work due to illness over a 12-month period. The majority of respondents (75.6%) indicated 10 or less missed work days. Of this group, the data indicated 1,475 respondents (68%) missed 5 or less workdays during this time. 4. Ongoing challenges to maintain interest and relevancy of certification. The study asked two questions pertaining to this topic: If you have never been certified, what barriers prevented you from being certified? Select all that apply, and If you were once certified but your certifica- March-April 2011 Vol. 20/No. 2 73

4 Professional Issues TABLE 2. Agreement with the PVCT s by Intrinsic and Extrinsic Factors PVCT Value Percentage of Total Respondents (n=1,748) Who Strongly Agree and Agree with Value Percentage of Certified Respondents (n=1,383) Who Strongly Agree and Agree with Value Percentage of Non-Certified Respondents (n=365) Who Strongly Agree and Agree with Value Intrinsic Factors Enhances feeling of personal accomplishment 98.5% 99.1% 98.0% Provides personal satisfaction 98.5% 98.9% 96.6% Validates specialized knowledge 98.1% 99.8% 94.9% Indicates professional growth 97.4% 96.5% 93.9% Enhances professional credibility 96.7% 97.5% 94.5% Provides professional challenge 96.5% 96.7% 96.1% Provides evidence of professional commitment 96.1% 97.7% 90.3% Indicates attainment of a practice standard 96.7% 94.3% 91.8% Enhances personal confidence in clinical abilities 93.8% 95.3% 88.4% Indicates level of clinical competence 91.8% 93.7% 84.3% Provides evidence of accountability 90.0% 92.1% 82.3% Enhances professional autonomy 85.6% 86.0% 84.0% Extrinsic Factors Promotes recognition from employers 91.5% 91.8% 89.6% Promotes recognition from peers 91.0% 92.1% 86.8% Increases marketability 88.0% 88.1% 87.4% Promotes recognition from other health professionals 86.6% 86.5% 86.9% Increases consumer confidence 81.4% 81.6% 80.4% Increases salary 51.8% 50.3% 57.5% tion has lapsed, please identify why. Select all that apply. See Table 4 for responses to these questions. Data concerning barriers to certification indicate the top barriers for the MSNCB group were cost of the examination, discomfort with the test-taking process, and lack of institutional reward. Nurses who were certified and did not maintain their certification listed the fee for renewal as the primary cause for non-renewal; no longer working in the specialty ranked second among barriers. The lowest rated barrier for both certification and recertification was lack of access to continuing education. MSNCB offered its first exam in Because certification is valid for 5 years, the first group of certification renewals was coming due at the time of this study. Therefore the sample size of recertifying nurses was limited. 5. Impact of certification on retention of nurses. To ascertain potential impact of certification on retention, participants were asked to indicate their future employment plans. Data suggested retention rates will remain stable because 84.9% of the certified respondents indicated they have no plans to make a change in their employment. Only 12% stated they were currently looking for another employer, and 3.1% indicated they plan to retire soon. 6. Benefits and rewards to certified nurses. Responses to the question regarding incentives provided by institutions to promote or recognize certification indicate the top three incentives were reimbursement for exam fees (56.1%), listing of certification credentials on name tags and/or business cards (30.1%), and advancement on the nursing clinical/career ladder (27.6%). Only 10.5% of respondents indicated they received no incentives from their employers. Table 5 presents the findings for the MSNCB study group. 7. Value of certified nurses as perceived by managers. Responses from nurse managers validated positive perceptions of certification with their correspondingly high rate of agreement on the 74 March-April 2011 Vol. 20/No. 2

5 Medical-Surgical Nurses Perceived Value of Certification Study TABLE 3. Perceived Value of Certification by Medical-Surgical Nurses Compared to ABNS Study Respondents PVCT Value Percentage of MSNCB Respondents (n=1,748) Who Strongly Agree and Agree with Value Percentage of ABNS Respondents (n=11,427) Who Strongly Agree and Agree with Value Intrinsic Factors Enhances feeling of personal accomplishment 98.5% 98.0% Provides personal satisfaction 98.5% 97.3% Validates specialized knowledge 98.1% 97.3% Indicates professional growth 97.4% 95.3% Enhances professional credibility 96.7% 95.4% Provides professional challenge 96.5% 95.1% Provides evidence of professional commitment 96.1% 94.1% Indicates attainment of a practice standard 96.7% 93.5% Enhances personal confidence in clinical abilities 93.8% 88.2% Indicates level of clinical competence 91.8% 83.5% Provides evidence of accountability 90.0% 84.4% Enhances professional autonomy 85.6% 78.3% Extrinsic Factors MSNCB ABNS Promotes recognition from employers 91.5% 77.9% Promotes recognition from peers 91.0% 88.1% Increases marketability 88.0% 84.8% Promotes recognition from other health professionals 86.6% 84.0% Increases consumer confidence 81.4% 71.6% Increases salary 51.8% 41.6% Source: Niebuhr & Biel, certification value statements. As in the ABNS study (Niebuhr & Biel, 2007), a majority of responding nurse managers were certified (78.4%). This potentially increased their perceived value of certification. Table 6 reflects a general level of positive agreement (strongly agree and agree) across items for nurse manager response distributions. The top three factors most valued by nurse manager respondents were personal satisfaction (98.6%), validates specialized knowledge (98.6%), and enhanced feeling of personal accomplishment (98%). Increased salary was rated the least perceived value (48.7%) by nurse managers. Statistical Analysis In addition to the demographic and summary outcomes previously presented, the PVCT was examined for reliability using both Cronbach s alpha coefficients and a principle components factor analysis with varimax rotation. The reliability coefficient for the 18-survey items was α = 0.93, indicating a high degree of internal consistency (reliability) among the items. The factor analysis indicated both intrinsic and extrinsic factors were measured by this survey. These results document both the stability of PVCT items, and the equivalence of MSNCB and ABNS outcomes as measured by the instrument. Discussion Data indicated certified medicalsurgical nurses have a positive perception of the value of certification. In addition, results compare favorably with the perceived value of certification expressed by the ABNS group (Niebuhr & Biel, 2007). Results also demonstrated non-certified nurses and nurse managers have a positive perception of certification. Intrinsic rewards of certification received the highest ratings. Of the 18 certification value statements, only one certification value statement on the PVCT ( certification increases salary ) did not elicit agreement from a majority of respondents. Findings for medical-surgical certified nurses, non-certified nurses, March-April 2011 Vol. 20/No. 2 75

6 Professional Issues TABLE 4. Challenges and Barriers to Certification/Recertification for Medical-Surgical Nurses Response Count Barriers to Certification (n=431) Cost of examination 202 Discomfort with test-taking process 114 Lack of institutional reward 108 Lack of access to preparation courses or materials 97 Lack of institutional support 91 I did not pass the exam when I took it. 88 Lack of access to examination site 64 It costs too much to maintain credential. 50 Not relevant to my practice 31 No desire/no interest in certification 32 Lack of access to or availability of continuing education 17 Response Count Barriers to Recertification (n=133) Fee for renewal 48 No longer in the specialty 44 Inadequate or no compensation for certification 42 Cost of continuing education 33 Personal circumstances 26 Inadequate recognition for certification 24 No time for continuing education 22 No access to continuing education 9 TABLE 5. Benefits and Rewards to Certified Nurses Incentives Response Percent (n=1,669) Reimbursement for exam fees 56.1% Listing of certification credential(s) on name tag and/or 30.1% business card Advancement on the nursing clinical/career ladder 27.6% Publication of names in institutional newsletter or other 26.7% relevant literature Recognition as an expert in my field by my colleagues 26.4% An increase in salary 25.9% A one-time bonus, other than salary 23.3% Reimbursement for continuing education 22.4% Plaque displayed listing certified nurses 21.5% Annual recognition event (breakfast, luncheon) 18.8% Reimbursement for recertification fees 18.0% Paid time off for attending continuing education classes 16.3% Reimbursement for review courses 15.3% Paid time off for taking exams 11.9% No incentive 10.5% Retention in the position I held at the time 5.8% Promotion to a higher level position 3.6% and nurse managers support previously published studies assessing the value of certification (Wade, 2009). Again, these data are consistent with the ABNS results (Niebuhr & Biel, 2007). As more individuals earn the CMSRN credential, more opportunity will exist to study their perceptions and compare their responses to these baseline data. Although certification is perceived positively, barriers continue to exist concerning obtaining and maintaining this status. The MSNCB group identified cost of certification, discomfort with the test-taking process, and lack of institutional reward as the top barriers to pursuit of certification. For certified nurses, the most cited benefits and rewards for certification were reimbursement for exam fees, credentials listed on name tags or business cards, and advancement on a clinical ladder. Although intrinsic rewards outnumber extrinsic rewards, extrinsic rewards are the driving force behind nurses deciding to become certified or recertified (Bekemeier, 2007). Nursing Implications Results of the current study have implications for health care organizations, certified and noncertified nurses, and future research. Health Care Organizations The researchers found costs of obtaining and renewing/maintaining certification are the primary barriers to certification for medical-surgical nurses. If employers value having a large percentage of certified nurses in their workforce, some method of compensation for certification would be beneficial. This compensation could be in the form of a salary increase, paying for the certification exam, or a bonus to support recertification. While some aspects of obtaining and maintaining certification are the professional nurse s responsibility, employer incentives could demonstrate the way an organization values nursing certification. The Academy of Medical-Surgical Nurses takes the position health care organizations should promote certification as part 76 March-April 2011 Vol. 20/No. 2

7 Medical-Surgical Nurses Perceived Value of Certification Study TABLE 6. Value of Certified Nurses as Perceived by Nurse Managers Manager Sample (n=148) Intrinsic Factors Provides personal satisfaction 98.6% Validates specialized knowledge 98.6% Enhances feeling of personal accomplishment 98.0% Enhances professional credibility 97.3% Indicates professional growth 97.2% Indicates attainment of a practice standard 96.0% Provides evidence of professional commitment 95.9% Provides professional challenge 95.3% Enhances personal confidence in clinical abilities 92.6% Indicates level of clinical competence 91.3% Provides evidence of accountability 89.9% Enhances professional autonomy 96.4% Extrinsic Factors Promotes recognition from peers 92.7% Promotes recognition from employers 91.9% Promotes recognition from other health professionals 90.0% Increases marketability 89.2% Increases consumer confidence 79.8% Increases salary 48.7% of the medical-surgical nurse s career development plan (AMSN, 2009). Nurse managers support the value of certification and can play a key role in assisting medical-surgical nurses in pursuing certification. Medical-Surgical Nurses Results of this study demonstrate certification provides many rewards for the nurse. Medical-surgical nurses who are not certified are encouraged to explore the intrinsic and extrinsic benefits of certification, identify the barriers to becoming certified, and develop a plan to achieve this distinction. Non-certified nurses are encouraged to collaborate with their certified colleagues for inspiration and assistance in becoming certified. Certified nurses should take every opportunity to promote their achievement by introducing themselves as certified medical-surgical nurses to patients, wearing their certification pins, and publicly displaying their credentials. Certified medical-surgical nurses can serve as role models by becoming involved in AMSN, their professional specialty nursing organization, and partnering with MSNCB to advocate for certification. Future Research This study also is the first to report the internal consistency of the PVCT and support its two-factor structure using factor analysis. Reporting these statistical data is important for informing researchers who may desire to use the instrument in subsequent research. It is imperative studies examining nursing certification not only include nurses perceptions, but also include patient outcomes. Although certification is supported by the American Nurses Association and many nursing specialty organizations, it remains unclear as to whether certified nurses actually produce better patient outcomes than non-certified nurses. Conclusion Nursing licensure is intended to ensure minimal competency of professional nurses, while certification demonstrates nurses achievement of a high level of competence or expertise in a particular area or specialty. For this reason, factors affecting the perceived value of medicalsurgical nursing certification are of interest to MSNCB and AMSN. Results of this study, the first to examine the medical-surgical specialty exclusively, are a valuable contribution to medical-surgical nursing. Findings support results of other studies (Cary, 2001; Niebuhr & Biel, 2007), indicating medical-surgical nurses value certification for similar intrinsic and extrinsic reasons as nurses in other specialties and in other countries (Cary, 2001). REFERENCES Academy of Medical-Surgical Nurses (AMSN). (2009). AMSN practice/research position statements: Certification. Retrieved from AMSNMain.woa/1/wa/viewSection?s_id = &ss_id= & tname=positionscertification Bekemeier, B. (2007). Credentialing for public health nurses: Personally valued but not well recognized. Public Health Nursing, 24(5), Byrne, M., Valentine, W., & Carter, S. (2004). The value of certification-a research journey. AORN Journal, 79(4), , Cary, A. (2001). Certified registered nurses: Results of the study of the certified workforce. American Journal of Nursing, 101(1), Competency & Credentialing Institute. (2010). Survey tool/reliability and validity of PVCT. Retrieved from tute.org/educ_rsrc_surv.aspx Eisemon, N., & Cline, A. (2006). Guest editorial: The value of certification. Gastro - enterology Nursing, 29(6), Gladfelter, J. (2006). Nursing certification: Why it matters. Plastic Surgical Nursing, 26(4), Niebuhr, B., & Biel, M. (2007). The value of specialty nursing certification. Nursing Outlook, 55(4), Piazza, I.M., Donahue, M., Dykes, P.C., Griffin, M.Q., & Fitzpatrick, J.J. (2006). Differen - ces in perceptions of empowerment among nationally certified and noncertified nurses. Journal of Nursing Admini - stration, 36(5), Ridge, R. (2008). Nursing certification as a workforce strategy. Nursing Manage - ment, 39(8), continued from page 93 March-April 2011 Vol. 20/No. 2 77

8 Certification Study continued from page 77 Sayre, C., Wyant, S., & Karvonen, C. (2010). Effect of a medical-surgical practice and certification review course on clinical nursing practice. Journal for Nurses in Staff Development, 26(1), Sechrist, K.R., Valentine, W., & Berlin, L.E. (2006). Perceived value of certification among certified, noncertified, and administrative perioperative nurses. Journal of Professional Nursing, 22(4), Shirey, M.R.J. (2005). Celebrating certification in nursing: Forces of magnetism in action. Nursing Administration Quarterly, 29(3), Stromberg, M.F., Niebuhr, B., Prevost, S., Fabrey, L., Muenzen, P., Spence, C.,... Valentine, W. (2005). More than a title. Nursing Management, 36(5), Wade, C.H. (2009). Perceived effects of specialty nurse certification: A review of the literature. AORN Journal, 89(1), March-April 2011 Vol. 20/No. 2 93