The Hospice Journal
ISSN: 0742-969X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ippc19
Certification for Hospice Nurses? Assessment of Need Madalon O’Rawe Amenta To cite this article: Madalon O’Rawe Amenta (1992) Certification for Hospice Nurses? Assessment of Need, The Hospice Journal, 8:3, 73-87, DOI: 10.1080/0742-969X.1992.11882732 To link to this article: https://doi.org/10.1080/0742-969X.1992.11882732
Published online: 29 Aug 2017.
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Certification for Hospice Nurses? Assessment of Need Madalon O'Rawe Amenta
ABSTRACT. An assessment of need survey questionnaire sent to the hospice nursing community yielded a substantial return (1,550). The resp6ndents overwhelmingly endorsed a certification process. They also emphasized the value of hospice experience and caring personal attitudes over formal educational preparation both for hospice work and for certification purposes. The prefer ences of these nurses for various elements of a certification pro cess are compared to those revealed in a Delphi study of 16 hospice nursing leaders. Certain of their experiential and demo graphic characteristics are related to other research findings about the characteristics of hospice nurses. INTRODUCTION In response to many requests for information about the development of a certification process for hospice nurses, in June 1990 the Board of Directors of the Hospice Nurses Association (HNA) appointed an ad hoc certification committee to look into the matter. The committee was Madalon O'Rawe Amenta, RN, DPH, was Vice President of the Hospice Nurses Association at the time this study was conducted. She was also a member of that organization's ad hoc Certification Committee. Address correspondence to M. Amenta, 5512 Northumberland St., Pittsburgh, PA 15217. This study was partially funded by the Hospice Nurses Association. Other members of the Hospice Nurses Association ad hoc Certification Committee at the time the data were collected were Ruth Antonowich, BSN, RNC, MSA; Lynn McGinnis, BSN; and Joann Wegmann, RN, PhD. The author wishes to thank Joseph Amenta, MD, Ellen Berkowitz, MA, and Cherie Maharam, BS, for their assistance with data management. The Hospice Journal, Vol. 8(3) 1992 «:> 1992 by The Haworth Press, Inc. All rights reserved.
73
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charged with the detennination of need as well as with an exploration of the feasibility of establishing a certification process. Simply defined, certification is a voluntary credential that represents to the members of a professional group and to its pertinent consumer and interdisciplinary communities that the certified practitioner meets the specialty's accepted standards of knowledge, skills, and practice. Certifi cation carries with it strong implications for quality of care as well as for professional autonomy. The literature revealed that certification of nurses in various specialties was a growing phenomenon. A 1990 survey (Fickeissen, 1990) indicated there were 56 nursing specialties in the United States with operational certification programs. Thirty-five of the programs were administered through a certification board or corporation of the specialty organization, one through the National League for Nursing, and the other 19 through the American Nurses Association (ANA). All the certification procedures had educational and/or experiential requirements that a candidate sitting for an examination had to meet. All had requirements for maintaining certification through re-examination and/or demonstration of approved continuing education at specified intervals. The minimum cost of exami nation was $75; the maximum, $350. Numbers of nurses certified in the various specialties ranged from 29 to 31,000.
METHOD
Instrument We designed a 21 item needs assessment questionnaire to ascertain a measure of the desire for certification among hospice nurses. We also wanted to know what hospice nurses thought about the essential elements of a certification process-eligibility, cost, maintenance and recertification, and sponsorship and administration of the procedure. In addition we asked for educational, experiential, professional, and demographic infor mation. We urged those who received the questionnaire to copy it and to give it to all others who they thought might/should have an interest in it.
Distribution The National Hospice Organization (NHO) included a copy of the questionnaire in its April 1991, mailing to all members. Members of the
Special Focus: Certification of Hospice Nurses
75
Oncology Nursing Society Hospice Special Interest Group were sent copies of the questionnaire with an explanatory letter. Finally, the HNA attached a copy of the questionnaire to its Spring, 1991 newsletter.
RESULTS Response The response was immediate and copious. From mid-April until the beginning of September we entered data into the computer in order of arrival of 1,550 completed questionnaires. We tabulated returns from every contiguous state, as well as Alaska and Hawaii. Since not every respondent answered every question, in the analysis we calculated percentages on the basis of number answering. Where relevant in this report, we indicate response rate.
Characteristics of the Sample Sex, Marital Status, Educational Experience Our respondents as a group were overwhelmingly female (97.32%) and married (72.44%). Over two thirds (68.43 %) received their basic education either in an Associate Degree (AON) program (27.63%) or in a hospital school of nursing (diploma) (40.76%) and almost two thirds (64.15 %) cited some baccalaureate experience. Over one third (35.44%) held the Bachelor of Science in Nursing (BSN) as basic preparation or as a result of continuing with their education after becoming registered nurses (RN). Fourteen percent had gone on to the master's level and anoth er 14.6% either had a degree in another field or had accumulated credits toward one. Areas of concentration cited for these extra-RN non-nursing studies were arts, humanities, basic sciences, social sciences, languages, education, business administration, public administration, counseling, pastoral counseling or ministry, and social work (see Table 1) .
. Employment Characteristics About 90% (87.36%) had been employed in nursing 25 years or less (M = 16.21), almost three quarters (72.85%) between 6 and 20 years. Nearly all (96.96%) had worked in hospice 10 years or less (M = 4.03); three quarters (74.54%) between one and five years, a little more than one half (53.32%) between one and three. Of these currently employed hospice nurses, 58.31% were staff and
THE HOSPICE JOURNAL
76 Table 1
Educational Status of 1,550 Hospice Nurses Educational level
!l
%
Associate Degree
429
27.67
Diploma
631
40.71
Bachelor of Science in Nursing
549
35.42
Master's Degree
218
14.06
227
14. 65
(Field unspecified) Other degree or credits toward (Field unspecified)
Note.
Since many respondents have completed more than one type of
educational experience, total number is more than 1,500 and percentages total more than 100.
41.69% were management. Since the question asked only for position or job title, we assigned those who designated themselves director, supervi sor, coordinator or educator to the management category. Close to two thirds of these nurses worked full-time. Of the part-timers over a half (54.48%) worked two or three days a week and approximately another third (32.53%) worked four (see Table 2). Income
For the 89.35% responding to the question about income, the results were skewed toward the comfortable range for middle class Americans. Almost one half (46.14%) claimed approximate annual family income of over $50,000 (see Table 3).
77
Special Focus: Certification of Hospice Nurses Table 2 current Employment Cha rac teristics of Hospic e Nurses
n POSITIONa Staff
863
58.31
Management
617
41. 69
Full-time
971
64. 77
Part-time
528
35.22
< 8
20
3.92
8
22
4.39
9 - 16
78
15.56
17 - 24
195
38.92
25 - 32
163
32.53
23
4.59
TIME STATus b
HOURS PER WEEKc
> 33 aRespondents
1,480
(95.48%)
bRespondents
1,499
(96.70%)
501
(94.88%)
c
Respondents
The Certification Process . Desirability
Ninety-nine percent of the respondents answered the question "Do you support the development of a hospice nursing certification process?" Ninety one and seventy hundredths percent indicated YES. Although they were not specifically asked to give a rationale for their choice, several elaborated. The assenters made comments such as:
THE HOSPICE JOURNAL
78 Table 3
Approximate Annual Family Income in 1991 of 1.385 Hospice Nurses Income level (in dollars)
< 10,000
n
%
7
0.50
10,000 - 20,000
63
4.55
20,000 - 30,000
169
12.20
30,000 - 40,000
268
19.35
40,000 - 50,000
239
17.26
> 50,000
639
46.14
Hospice is a definite specialty and we deserve that status and recog nition. We've been waiting for this for a long time. It is important for our nurses to have recognition and I support this, but I have reservations about excluding some of our peers like LVNs. Please cut the red tape and let's get on with it. Those who did not want a hospice nursing certification process were more likely to supply a rationale. Their statements were passionate in tone, deeply felt, and highly expressive; and they sorted themselves into three categories. Some were pro-compassion and pro-caring, strongly emphasizing the emotional sensitivity and feeling aspects of hospice nursing. They expressed the value of personal approach and experience over didactic knowledge as the defining standard of excel lence. Others were anti-the standardization of both knowledge and practice. They were specifically anti-test. Still others were anti-regula tion, anti-bureaucracy, anti-cost.
Special Focus: Certification of Hospice Nurses
79
Certification will eliminate many well-qualified nurses who might not be able to pass a test. We have had tests up to our ears. I for one would not consider talcing a test. Compassion for the living and dying plus good basic nursing skills are all that are required. How can you test that? What is important for a hospice nurse is compassion, caring, com mon sense, good nursing skills-not more courses, degrees, and tests. I feel certification will be an excuse to charge exorbitant fees and allow a group to dictate more rules and regulations while collecting a fat salary. I think we are doing ourselves as professional RNs a disservice by the certification process. We are subverting each other and devalu ing our RN in an effort to make CE agencies and regulatory agen cies rich. Eligibility Requiremellfs Educational. Although 40 % of the respondents saw the RN, whether achieved through a diploma or an AON program, sufficient as an edu cational requirement for candidates sitting for a hospice nurse certifi cation examination, over 25 % indicated the BSN as the desideratum (see Table 4). The written comments that accompanied responses to this item re vealed among other things about hospice nurses, a sense of egalitarian ism and team solidarity. Several said they thought that LVNs and LPNs-since they were essential to the team and they too deserved recognition for their skilled contributions-should not be left out of the certification process. Many, again, emphasized personality characteris tics over educational credentials.
The entry level degree is irrelevant. Are there courses for caring, understanding, feeling comfortable with the dying? The question of a body of hospice nursing knowledge was raised by some who said we need to more clearly define that knowledge.
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THE HOSPICE JOURNAL
Table 4 1,518 Hospice Nurses' Views of Educational Requirements for Eligibility for a Certification Examination
n
%
RN
612
40.31
BSN
414
27.27
23
1. 52
383
25.23
86
5.67
Educational level
MS CEUS within a designated time Other
Hospice nurses need to develop a firm knowledge base before cer tification. We need research into what hospice care is. Others cited the lack of formal nursing education curriculum for hospice care as an issue needing attention. I believe that continuing education is the most practical route right now. Does any nursing education program have care of the dying as a major or central topic? The overwhelming emphasis, however, was on the need for experience as the most significant element of eligibility. I don't feel the level of education would be a good indication of whether the candidate would be a good hospice nurse-experience 1s the most important thing.
Experiential. When asked what hospice experience requirements should be expected of a nurse sitting for an examination, 13.54% thought simply current employment in a hospice was sufficient. The rest indicated cur-
Special Focus: Certification of Hospice Nurses
81
rent employment "plus." The largest group (41.67%) thought a year's recent experience was adequate, 35.47% thought two, and 6.8% thought three. Close to 85%, then, indicated that one to three years' recent expe rience ought to be required. It should be noted that the term "recent" was not defined. More comments about the value of experience in contributing to excellence in hospice nursing practice were elicited by this item. Experience is the most important indicator. Candidates should not only have hospice, but community health and medical/surgical nursing background. Must have three years' nursing experience ·before working in a hos pice. In addition to hospice and nursing experience, should have 'life' experience-losses, therapy, active spiritual (not religious) practice. Preparation for Certification Examination
The item "Do you support the creation of a core curriculum document to be made available with a study guide for those wishing to sit for the certification examination?" elicited the highest response in the study, one less than the total sample. Almost all (97.41%) answered YES. Only slightly more than one quarter of these respondents (26.27%), however, thought class presentations for Continuing Education Unit (CEU) credit should be a requirement for taking an examination, about 75 % thinking they should be optional. Recertification. Only 3% of the 1,536 respondents indicated re-exami nation as a "reasonable" method of maintaining certification. Seventy eight and thirty-eight hundredths percent favored CEUs and 18.68% preferred an unspecified combination of examination and CEUs. As to the frequency of the recertification process, well over half (61.25 %) of the 1,471 responding to the question thought the recertification process should take place in two or three years, 3.26% thought annually, and 3. 19% checked OTHER, giving explanatory statements that fell into two categories-"more than five years" and "never." Cost
The scale of options presented for the item "What do you think the ap proximate cost of the initial certification examination or process should
THE HOSPICE JOURNAL
82
be?" embedded the range of fees for certification examinations of the various nursing specialties indicated in the literature. Our respondents oveIWhelmingly (90.68%) chose the two lowest categories-$75-$100 (71.93%) and $101-$200 (18.75%) (see Table 5). Of the 6.7% who checked "OTHER Please Specify," several pleaded inability to answer because of lack of knowledge of the subject and many stated the fee should be less than $75. Organizations Sponsoring organization. Two thirds (66.77%) indicated the HNA as their choice of administering agency for the certification process, 17.48 % the ANA. Membership in organizations. This choice of administering organiza tion would not seem to be influenced by professional membership loyalty in that only 18.26% of these 1,550 hospice nurses were HNA members. This is roughly the same percentage (17.48 % ) who were ANA members. Twelve and thirty-two hundredths percent claimed membership in the NHO Council of Health Professionals and another 17. 94% in other pro fessional associations. Among them were: Table 5 Opinions of 1,493 Hospice Nurses about Approximate Cost of an Initial Certification Examination
n
%
1,074
71. 93
101 - 200
280
18.75
201 - 300
35
2.34
301 - 400
2
0.13
401 - 500
1
0.07
101
6.76
Amount (in dollars)
75 - 100
Other
Special Focus: Certification of Hospice Nurses
• • • • • • • • •
83
Oncology Nursing Society Sigma Theta Tau American Holistic Nurses Association American Association of Critical Care Nurses American Association of Continuity of Care Black Nurses Association American Academy of Pain Management Academy of Palliative Care Nurses Various State Hospice Associations
Certification in other nursing specialties. Almost all (96. 9%) of the 1,550 nurses in the sample answered the question about certification in another specialty, a little over a fifth (21.9%) claiming some sort of certification. The greatest percentage (5.9%) were certified in oncology, 2.3 % were certified in community or public health, followed by l. 7 % in critical care and coronary care, 1.2% in medical/surgical nursing, and 1.1% in gerontology. The rest claimed certification in a smattering of specialties-chemotherapy, administration, enterostomal therapy, counsel ing, psychiatric nursing, childbirth education, nephrology, infusion, reha bilitation, bereavement, AIDS instruction, pain management, acupunc ture, and Shiatsu massage.
DISCUSSION The Volume of Response, the Importance of Certification as an Issue, and the Characteristics of Hospice Nurses Although this was not a scientifically selected sample, we deem the volume of response elicited by the questionnaire a matter of consequence. We tabulated and analyzed 1,550 returns in September of 1991. In No vember we counted over l , 700 and as late as February of 1992 they were still trickling in. The response was also remarkable in the breadth of its geographic distribution-every state in the Union. These large numbers and the widespread distribution lend substance to the results. The prolific response is an indication of intensity of interest in that people in general do not return mailed surveys unless the topic "matters" to them. Nurses in particular are not usually activists. It is an operational rule of life in nursing organizations that participants tum out in the num bers for actions and speakers only when the issues are "bread and butter" ones.
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THE HOSPICE JOURNAL
Nor are nurses generally joiners. Another given in the nursing organi zations community is that membership is always a small fraction of poten tial. The data in this study appear to bear that out. Fifty percent of these nurses did not belong to any professional organization and only 20% belonged to more than one. Of the organizations directly concerned with hospice nursing, 18.26% were members of HNA and 12.32% of the NHO Council of Health Professionals. It is interesting to note that shortly following this study there was a rise in new memberships in HNA. On the other hand, hospice nurses have been shown to differ from nurses in traditional settings along several basic personality dimensions (Amenta, 1991). They have been found to be more assertive, imaginative, venturesome, forthright, free thinking, and independent. This may ac count in part for their remarkable level of participation in response to this questionnaire. The hospice nurses in this sample would appear to be better educated than the nursing population at large. With 77. 7 % of these hospice nurses having practiced nursing for between 6 and 25 years and 35% BSN and 14% Master's prepared, they seem to have been ahead of their time. In 1991, 26 % of new nursing graduates nationally were from BSN programs. This was hailed, after years of struggle to make the BSN the entry level degree, as a greater proportion than ever before (Nursing and Health Care, February, 1992). With approximately 50% claiming annual family income of over $50,000, the hospice nurses in this sample could be said to be comfort ably off financially. This might be related to their relatively advanced educational levels, length of time worked, or the large proportion of managers. In that a third of the respondents worked part time, however, family income level this high is more likely a function of marital status. Indeed, marital status and income level were among the few relationships in the study that approached statistical significance. The income factor may also be relevant to participation levels in that, in general, those more comfortably off have more discretionary time as well as money. That close to 90% of the respondents answered the question about income is also remarkable. It is part of the conventional wisdom of sur vey research that questions related to income are only slightly less sensi tive than those dealing with religion. They do not generally yield rich response. Perhaps these hospice nurses were demonstrating their high levels of forthrightness. The longevity in nursing practice of a large majority of the sample contrasted with the relatively short time they have worked in hospice care is suggestive of two things. Hospices as institutions in considerable num-
Special Focus: Certification of Hospice Nurses
85
bers have been in existence only a little less than a decade. These hospice nurses in keeping with their demonstrated assertiveness, venturesomeness, and independence might well be assumed to have purposefully chosen the field after long experience of practice in other settings. The high proportion of managers to staff may reflect that hospices tend to be small organizations; or it may reflect the relatively high educational levels of this sample. It may also reflect a characteristic of the hospice nursing cosmos. Bene and Foxhall (1991) found in a comparison of hos pice nurses and medical/surgical nurses a significantly higher number of hospice nurses in management positions. In our study, we cannot over look the possibility that the preponderance of managers partly reflects an artifact of the study instrument and the analysis. The question asked for "job title" and we assigned those who answered "coordinator" to the management category. Depending on the size and organizational structure of the hospice, the coordinator position could vary.
The Certification Process In discussing the certification process 1t 1s mstructive to compare the findings of this survey of 1,550 grassroots hospice nurses with those of a Delphi study of 16 hospice nursing leaders (Knight & Knight, 1992, see this issue). The data for the Delphi project were collected earlier and the results were not known at the time this study was conducted. Each group unequivocally advocated a certification procedure. Each addressed the need for isolation and organization of hospice content into the mainstream nursing educational curriculum, and each acknowledged hospice experience as a more critical determinant of expertise than formal nursing educational preparation. Each agreed that at least one to three years of hospice experience should be required as a condition of eligibili ty. They also agreed that CEUs rather than examination should be the rule for maintenance of certification and/or recertification. Ironically, while the leaders deemed RN preparation adequate, one quarter of the grassroots group indicated the BSN as the basic educational criterion for eligibility. The leaders, since they unanimously endorsed CEUs as the standard, indicated a two year interval for recertification. The grassroots, about 22 % of whom opted for examination and CEUs in unspecified combina tions, thought recertification should take place every two to three years. On this dimension hospice nurses, whether leaders or at the grassroots, agreed more with each other than with the apparent realities of the wider workaday world of commercial certification testing firms. In their experi-
86
THE HOSPICE JOURNAL
ence it is more usual for nursing specialties to require examinations for recertification at approximately five year intervals (S. A. Henry, Presi dent, Professional Testing Corporation; personal communication, January 25, 1992). As to costs, the grassroots nurses in this study opted, almost unani mously, for fees ranging from between $75 (or less) and $200. The lead ers recommended those charged by other certifying organizations and that they be "reasonable." Other certifying organizations on average charge between $100-$200 (S. A. Henry, personal communication, January 25, 1992). The choice by a very wide margin of the grassroots group of HNA over either ANA or NHO-the leader group's first choice among the three closely ranked-as the sponsoring agency for the certification process might be a reflection of the relatively fledgling status of the HNA at the time the data from the leader group were collected.
RECOMMENDATIONS One recommendation based on the findings of this study is that better designed research be conducted to further contribute to the data base on the characteristics of hospice nurses. Because this project was undertaken primarily as an administrative task, and because we had no idea of the numbers who would respond, we did not field test the questionnaire. As a result there was ambiguity in the wording of some of the items and responses were often unclear. With a better questionnaire and a scientific sampling scheme the findings of a similar study would be more securely generalizable and strengths of relationships could reasonably be explored. Delineation of such conditions as hospice age and size, model, lo cation-urban, rural-would be of value not only to those with professional interest in hospice nurses and to nursing in general, but to hospice man agers, as well. The more obvious recommendation would be to mount a hospice nurs es certification program. Interest is clearly high among hospice nurses. There is also organizational support in that the Board of Directors of the HNA is exploring feasibility. Free standing hospice organizations, as a consequence of the abandonment of the hospice accreditation program by the Joint Commission on Accreditation of Healthcare Organizations, have also expressed interest. Indeed, it would appear that certification for hospice nurses has become a "bread and butter" issue not only for nurses but for other segments of the hospice community.
Special Focus: Certification of Hospice Nurses
87
REFERENCES Amenta, M. (1991, November). Characteristics of hospice nurses revisited. Paper presented at the Annual Meeting of the National Hospice Organization, Seat tle, WA. Bene, 8., & Foxhall, M.J. (1991). Death anxiety and job stress in hospice and medical-surgical nurses. The Hospice Journal, 7, 25-41. Fickeissen, J. L. (1990). 56 ways to get certified. American Journal of Nursing, 90, 50-57. Knight, C. F., & Knight, P. F. (1992). Organization factors to consider when developing a certification program for hospice nurses: A Delphi study. 171e Hospice Journal 8(3). (1992, February) Upsurge in 1991 nursing school enrollments. 8(3). Nursing and Health Care, p. 100.
ISSN: 0742-969X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ippc19
Certification for Hospice Nurses? Assessment of Need Madalon O’Rawe Amenta To cite this article: Madalon O’Rawe Amenta (1992) Certification for Hospice Nurses? Assessment of Need, The Hospice Journal, 8:3, 73-87, DOI: 10.1080/0742-969X.1992.11882732 To link to this article: https://doi.org/10.1080/0742-969X.1992.11882732
Published online: 29 Aug 2017.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ippc19
Certification for Hospice Nurses? Assessment of Need Madalon O'Rawe Amenta
ABSTRACT. An assessment of need survey questionnaire sent to the hospice nursing community yielded a substantial return (1,550). The resp6ndents overwhelmingly endorsed a certification process. They also emphasized the value of hospice experience and caring personal attitudes over formal educational preparation both for hospice work and for certification purposes. The prefer ences of these nurses for various elements of a certification pro cess are compared to those revealed in a Delphi study of 16 hospice nursing leaders. Certain of their experiential and demo graphic characteristics are related to other research findings about the characteristics of hospice nurses. INTRODUCTION In response to many requests for information about the development of a certification process for hospice nurses, in June 1990 the Board of Directors of the Hospice Nurses Association (HNA) appointed an ad hoc certification committee to look into the matter. The committee was Madalon O'Rawe Amenta, RN, DPH, was Vice President of the Hospice Nurses Association at the time this study was conducted. She was also a member of that organization's ad hoc Certification Committee. Address correspondence to M. Amenta, 5512 Northumberland St., Pittsburgh, PA 15217. This study was partially funded by the Hospice Nurses Association. Other members of the Hospice Nurses Association ad hoc Certification Committee at the time the data were collected were Ruth Antonowich, BSN, RNC, MSA; Lynn McGinnis, BSN; and Joann Wegmann, RN, PhD. The author wishes to thank Joseph Amenta, MD, Ellen Berkowitz, MA, and Cherie Maharam, BS, for their assistance with data management. The Hospice Journal, Vol. 8(3) 1992 «:> 1992 by The Haworth Press, Inc. All rights reserved.
73
74
lliE HOSPICE JOURNAL
charged with the detennination of need as well as with an exploration of the feasibility of establishing a certification process. Simply defined, certification is a voluntary credential that represents to the members of a professional group and to its pertinent consumer and interdisciplinary communities that the certified practitioner meets the specialty's accepted standards of knowledge, skills, and practice. Certifi cation carries with it strong implications for quality of care as well as for professional autonomy. The literature revealed that certification of nurses in various specialties was a growing phenomenon. A 1990 survey (Fickeissen, 1990) indicated there were 56 nursing specialties in the United States with operational certification programs. Thirty-five of the programs were administered through a certification board or corporation of the specialty organization, one through the National League for Nursing, and the other 19 through the American Nurses Association (ANA). All the certification procedures had educational and/or experiential requirements that a candidate sitting for an examination had to meet. All had requirements for maintaining certification through re-examination and/or demonstration of approved continuing education at specified intervals. The minimum cost of exami nation was $75; the maximum, $350. Numbers of nurses certified in the various specialties ranged from 29 to 31,000.
METHOD
Instrument We designed a 21 item needs assessment questionnaire to ascertain a measure of the desire for certification among hospice nurses. We also wanted to know what hospice nurses thought about the essential elements of a certification process-eligibility, cost, maintenance and recertification, and sponsorship and administration of the procedure. In addition we asked for educational, experiential, professional, and demographic infor mation. We urged those who received the questionnaire to copy it and to give it to all others who they thought might/should have an interest in it.
Distribution The National Hospice Organization (NHO) included a copy of the questionnaire in its April 1991, mailing to all members. Members of the
Special Focus: Certification of Hospice Nurses
75
Oncology Nursing Society Hospice Special Interest Group were sent copies of the questionnaire with an explanatory letter. Finally, the HNA attached a copy of the questionnaire to its Spring, 1991 newsletter.
RESULTS Response The response was immediate and copious. From mid-April until the beginning of September we entered data into the computer in order of arrival of 1,550 completed questionnaires. We tabulated returns from every contiguous state, as well as Alaska and Hawaii. Since not every respondent answered every question, in the analysis we calculated percentages on the basis of number answering. Where relevant in this report, we indicate response rate.
Characteristics of the Sample Sex, Marital Status, Educational Experience Our respondents as a group were overwhelmingly female (97.32%) and married (72.44%). Over two thirds (68.43 %) received their basic education either in an Associate Degree (AON) program (27.63%) or in a hospital school of nursing (diploma) (40.76%) and almost two thirds (64.15 %) cited some baccalaureate experience. Over one third (35.44%) held the Bachelor of Science in Nursing (BSN) as basic preparation or as a result of continuing with their education after becoming registered nurses (RN). Fourteen percent had gone on to the master's level and anoth er 14.6% either had a degree in another field or had accumulated credits toward one. Areas of concentration cited for these extra-RN non-nursing studies were arts, humanities, basic sciences, social sciences, languages, education, business administration, public administration, counseling, pastoral counseling or ministry, and social work (see Table 1) .
. Employment Characteristics About 90% (87.36%) had been employed in nursing 25 years or less (M = 16.21), almost three quarters (72.85%) between 6 and 20 years. Nearly all (96.96%) had worked in hospice 10 years or less (M = 4.03); three quarters (74.54%) between one and five years, a little more than one half (53.32%) between one and three. Of these currently employed hospice nurses, 58.31% were staff and
THE HOSPICE JOURNAL
76 Table 1
Educational Status of 1,550 Hospice Nurses Educational level
!l
%
Associate Degree
429
27.67
Diploma
631
40.71
Bachelor of Science in Nursing
549
35.42
Master's Degree
218
14.06
227
14. 65
(Field unspecified) Other degree or credits toward (Field unspecified)
Note.
Since many respondents have completed more than one type of
educational experience, total number is more than 1,500 and percentages total more than 100.
41.69% were management. Since the question asked only for position or job title, we assigned those who designated themselves director, supervi sor, coordinator or educator to the management category. Close to two thirds of these nurses worked full-time. Of the part-timers over a half (54.48%) worked two or three days a week and approximately another third (32.53%) worked four (see Table 2). Income
For the 89.35% responding to the question about income, the results were skewed toward the comfortable range for middle class Americans. Almost one half (46.14%) claimed approximate annual family income of over $50,000 (see Table 3).
77
Special Focus: Certification of Hospice Nurses Table 2 current Employment Cha rac teristics of Hospic e Nurses
n POSITIONa Staff
863
58.31
Management
617
41. 69
Full-time
971
64. 77
Part-time
528
35.22
< 8
20
3.92
8
22
4.39
9 - 16
78
15.56
17 - 24
195
38.92
25 - 32
163
32.53
23
4.59
TIME STATus b
HOURS PER WEEKc
> 33 aRespondents
1,480
(95.48%)
bRespondents
1,499
(96.70%)
501
(94.88%)
c
Respondents
The Certification Process . Desirability
Ninety-nine percent of the respondents answered the question "Do you support the development of a hospice nursing certification process?" Ninety one and seventy hundredths percent indicated YES. Although they were not specifically asked to give a rationale for their choice, several elaborated. The assenters made comments such as:
THE HOSPICE JOURNAL
78 Table 3
Approximate Annual Family Income in 1991 of 1.385 Hospice Nurses Income level (in dollars)
< 10,000
n
%
7
0.50
10,000 - 20,000
63
4.55
20,000 - 30,000
169
12.20
30,000 - 40,000
268
19.35
40,000 - 50,000
239
17.26
> 50,000
639
46.14
Hospice is a definite specialty and we deserve that status and recog nition. We've been waiting for this for a long time. It is important for our nurses to have recognition and I support this, but I have reservations about excluding some of our peers like LVNs. Please cut the red tape and let's get on with it. Those who did not want a hospice nursing certification process were more likely to supply a rationale. Their statements were passionate in tone, deeply felt, and highly expressive; and they sorted themselves into three categories. Some were pro-compassion and pro-caring, strongly emphasizing the emotional sensitivity and feeling aspects of hospice nursing. They expressed the value of personal approach and experience over didactic knowledge as the defining standard of excel lence. Others were anti-the standardization of both knowledge and practice. They were specifically anti-test. Still others were anti-regula tion, anti-bureaucracy, anti-cost.
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Certification will eliminate many well-qualified nurses who might not be able to pass a test. We have had tests up to our ears. I for one would not consider talcing a test. Compassion for the living and dying plus good basic nursing skills are all that are required. How can you test that? What is important for a hospice nurse is compassion, caring, com mon sense, good nursing skills-not more courses, degrees, and tests. I feel certification will be an excuse to charge exorbitant fees and allow a group to dictate more rules and regulations while collecting a fat salary. I think we are doing ourselves as professional RNs a disservice by the certification process. We are subverting each other and devalu ing our RN in an effort to make CE agencies and regulatory agen cies rich. Eligibility Requiremellfs Educational. Although 40 % of the respondents saw the RN, whether achieved through a diploma or an AON program, sufficient as an edu cational requirement for candidates sitting for a hospice nurse certifi cation examination, over 25 % indicated the BSN as the desideratum (see Table 4). The written comments that accompanied responses to this item re vealed among other things about hospice nurses, a sense of egalitarian ism and team solidarity. Several said they thought that LVNs and LPNs-since they were essential to the team and they too deserved recognition for their skilled contributions-should not be left out of the certification process. Many, again, emphasized personality characteris tics over educational credentials.
The entry level degree is irrelevant. Are there courses for caring, understanding, feeling comfortable with the dying? The question of a body of hospice nursing knowledge was raised by some who said we need to more clearly define that knowledge.
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Table 4 1,518 Hospice Nurses' Views of Educational Requirements for Eligibility for a Certification Examination
n
%
RN
612
40.31
BSN
414
27.27
23
1. 52
383
25.23
86
5.67
Educational level
MS CEUS within a designated time Other
Hospice nurses need to develop a firm knowledge base before cer tification. We need research into what hospice care is. Others cited the lack of formal nursing education curriculum for hospice care as an issue needing attention. I believe that continuing education is the most practical route right now. Does any nursing education program have care of the dying as a major or central topic? The overwhelming emphasis, however, was on the need for experience as the most significant element of eligibility. I don't feel the level of education would be a good indication of whether the candidate would be a good hospice nurse-experience 1s the most important thing.
Experiential. When asked what hospice experience requirements should be expected of a nurse sitting for an examination, 13.54% thought simply current employment in a hospice was sufficient. The rest indicated cur-
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81
rent employment "plus." The largest group (41.67%) thought a year's recent experience was adequate, 35.47% thought two, and 6.8% thought three. Close to 85%, then, indicated that one to three years' recent expe rience ought to be required. It should be noted that the term "recent" was not defined. More comments about the value of experience in contributing to excellence in hospice nursing practice were elicited by this item. Experience is the most important indicator. Candidates should not only have hospice, but community health and medical/surgical nursing background. Must have three years' nursing experience ·before working in a hos pice. In addition to hospice and nursing experience, should have 'life' experience-losses, therapy, active spiritual (not religious) practice. Preparation for Certification Examination
The item "Do you support the creation of a core curriculum document to be made available with a study guide for those wishing to sit for the certification examination?" elicited the highest response in the study, one less than the total sample. Almost all (97.41%) answered YES. Only slightly more than one quarter of these respondents (26.27%), however, thought class presentations for Continuing Education Unit (CEU) credit should be a requirement for taking an examination, about 75 % thinking they should be optional. Recertification. Only 3% of the 1,536 respondents indicated re-exami nation as a "reasonable" method of maintaining certification. Seventy eight and thirty-eight hundredths percent favored CEUs and 18.68% preferred an unspecified combination of examination and CEUs. As to the frequency of the recertification process, well over half (61.25 %) of the 1,471 responding to the question thought the recertification process should take place in two or three years, 3.26% thought annually, and 3. 19% checked OTHER, giving explanatory statements that fell into two categories-"more than five years" and "never." Cost
The scale of options presented for the item "What do you think the ap proximate cost of the initial certification examination or process should
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82
be?" embedded the range of fees for certification examinations of the various nursing specialties indicated in the literature. Our respondents oveIWhelmingly (90.68%) chose the two lowest categories-$75-$100 (71.93%) and $101-$200 (18.75%) (see Table 5). Of the 6.7% who checked "OTHER Please Specify," several pleaded inability to answer because of lack of knowledge of the subject and many stated the fee should be less than $75. Organizations Sponsoring organization. Two thirds (66.77%) indicated the HNA as their choice of administering agency for the certification process, 17.48 % the ANA. Membership in organizations. This choice of administering organiza tion would not seem to be influenced by professional membership loyalty in that only 18.26% of these 1,550 hospice nurses were HNA members. This is roughly the same percentage (17.48 % ) who were ANA members. Twelve and thirty-two hundredths percent claimed membership in the NHO Council of Health Professionals and another 17. 94% in other pro fessional associations. Among them were: Table 5 Opinions of 1,493 Hospice Nurses about Approximate Cost of an Initial Certification Examination
n
%
1,074
71. 93
101 - 200
280
18.75
201 - 300
35
2.34
301 - 400
2
0.13
401 - 500
1
0.07
101
6.76
Amount (in dollars)
75 - 100
Other
Special Focus: Certification of Hospice Nurses
• • • • • • • • •
83
Oncology Nursing Society Sigma Theta Tau American Holistic Nurses Association American Association of Critical Care Nurses American Association of Continuity of Care Black Nurses Association American Academy of Pain Management Academy of Palliative Care Nurses Various State Hospice Associations
Certification in other nursing specialties. Almost all (96. 9%) of the 1,550 nurses in the sample answered the question about certification in another specialty, a little over a fifth (21.9%) claiming some sort of certification. The greatest percentage (5.9%) were certified in oncology, 2.3 % were certified in community or public health, followed by l. 7 % in critical care and coronary care, 1.2% in medical/surgical nursing, and 1.1% in gerontology. The rest claimed certification in a smattering of specialties-chemotherapy, administration, enterostomal therapy, counsel ing, psychiatric nursing, childbirth education, nephrology, infusion, reha bilitation, bereavement, AIDS instruction, pain management, acupunc ture, and Shiatsu massage.
DISCUSSION The Volume of Response, the Importance of Certification as an Issue, and the Characteristics of Hospice Nurses Although this was not a scientifically selected sample, we deem the volume of response elicited by the questionnaire a matter of consequence. We tabulated and analyzed 1,550 returns in September of 1991. In No vember we counted over l , 700 and as late as February of 1992 they were still trickling in. The response was also remarkable in the breadth of its geographic distribution-every state in the Union. These large numbers and the widespread distribution lend substance to the results. The prolific response is an indication of intensity of interest in that people in general do not return mailed surveys unless the topic "matters" to them. Nurses in particular are not usually activists. It is an operational rule of life in nursing organizations that participants tum out in the num bers for actions and speakers only when the issues are "bread and butter" ones.
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Nor are nurses generally joiners. Another given in the nursing organi zations community is that membership is always a small fraction of poten tial. The data in this study appear to bear that out. Fifty percent of these nurses did not belong to any professional organization and only 20% belonged to more than one. Of the organizations directly concerned with hospice nursing, 18.26% were members of HNA and 12.32% of the NHO Council of Health Professionals. It is interesting to note that shortly following this study there was a rise in new memberships in HNA. On the other hand, hospice nurses have been shown to differ from nurses in traditional settings along several basic personality dimensions (Amenta, 1991). They have been found to be more assertive, imaginative, venturesome, forthright, free thinking, and independent. This may ac count in part for their remarkable level of participation in response to this questionnaire. The hospice nurses in this sample would appear to be better educated than the nursing population at large. With 77. 7 % of these hospice nurses having practiced nursing for between 6 and 25 years and 35% BSN and 14% Master's prepared, they seem to have been ahead of their time. In 1991, 26 % of new nursing graduates nationally were from BSN programs. This was hailed, after years of struggle to make the BSN the entry level degree, as a greater proportion than ever before (Nursing and Health Care, February, 1992). With approximately 50% claiming annual family income of over $50,000, the hospice nurses in this sample could be said to be comfort ably off financially. This might be related to their relatively advanced educational levels, length of time worked, or the large proportion of managers. In that a third of the respondents worked part time, however, family income level this high is more likely a function of marital status. Indeed, marital status and income level were among the few relationships in the study that approached statistical significance. The income factor may also be relevant to participation levels in that, in general, those more comfortably off have more discretionary time as well as money. That close to 90% of the respondents answered the question about income is also remarkable. It is part of the conventional wisdom of sur vey research that questions related to income are only slightly less sensi tive than those dealing with religion. They do not generally yield rich response. Perhaps these hospice nurses were demonstrating their high levels of forthrightness. The longevity in nursing practice of a large majority of the sample contrasted with the relatively short time they have worked in hospice care is suggestive of two things. Hospices as institutions in considerable num-
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85
bers have been in existence only a little less than a decade. These hospice nurses in keeping with their demonstrated assertiveness, venturesomeness, and independence might well be assumed to have purposefully chosen the field after long experience of practice in other settings. The high proportion of managers to staff may reflect that hospices tend to be small organizations; or it may reflect the relatively high educational levels of this sample. It may also reflect a characteristic of the hospice nursing cosmos. Bene and Foxhall (1991) found in a comparison of hos pice nurses and medical/surgical nurses a significantly higher number of hospice nurses in management positions. In our study, we cannot over look the possibility that the preponderance of managers partly reflects an artifact of the study instrument and the analysis. The question asked for "job title" and we assigned those who answered "coordinator" to the management category. Depending on the size and organizational structure of the hospice, the coordinator position could vary.
The Certification Process In discussing the certification process 1t 1s mstructive to compare the findings of this survey of 1,550 grassroots hospice nurses with those of a Delphi study of 16 hospice nursing leaders (Knight & Knight, 1992, see this issue). The data for the Delphi project were collected earlier and the results were not known at the time this study was conducted. Each group unequivocally advocated a certification procedure. Each addressed the need for isolation and organization of hospice content into the mainstream nursing educational curriculum, and each acknowledged hospice experience as a more critical determinant of expertise than formal nursing educational preparation. Each agreed that at least one to three years of hospice experience should be required as a condition of eligibili ty. They also agreed that CEUs rather than examination should be the rule for maintenance of certification and/or recertification. Ironically, while the leaders deemed RN preparation adequate, one quarter of the grassroots group indicated the BSN as the basic educational criterion for eligibility. The leaders, since they unanimously endorsed CEUs as the standard, indicated a two year interval for recertification. The grassroots, about 22 % of whom opted for examination and CEUs in unspecified combina tions, thought recertification should take place every two to three years. On this dimension hospice nurses, whether leaders or at the grassroots, agreed more with each other than with the apparent realities of the wider workaday world of commercial certification testing firms. In their experi-
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ence it is more usual for nursing specialties to require examinations for recertification at approximately five year intervals (S. A. Henry, Presi dent, Professional Testing Corporation; personal communication, January 25, 1992). As to costs, the grassroots nurses in this study opted, almost unani mously, for fees ranging from between $75 (or less) and $200. The lead ers recommended those charged by other certifying organizations and that they be "reasonable." Other certifying organizations on average charge between $100-$200 (S. A. Henry, personal communication, January 25, 1992). The choice by a very wide margin of the grassroots group of HNA over either ANA or NHO-the leader group's first choice among the three closely ranked-as the sponsoring agency for the certification process might be a reflection of the relatively fledgling status of the HNA at the time the data from the leader group were collected.
RECOMMENDATIONS One recommendation based on the findings of this study is that better designed research be conducted to further contribute to the data base on the characteristics of hospice nurses. Because this project was undertaken primarily as an administrative task, and because we had no idea of the numbers who would respond, we did not field test the questionnaire. As a result there was ambiguity in the wording of some of the items and responses were often unclear. With a better questionnaire and a scientific sampling scheme the findings of a similar study would be more securely generalizable and strengths of relationships could reasonably be explored. Delineation of such conditions as hospice age and size, model, lo cation-urban, rural-would be of value not only to those with professional interest in hospice nurses and to nursing in general, but to hospice man agers, as well. The more obvious recommendation would be to mount a hospice nurs es certification program. Interest is clearly high among hospice nurses. There is also organizational support in that the Board of Directors of the HNA is exploring feasibility. Free standing hospice organizations, as a consequence of the abandonment of the hospice accreditation program by the Joint Commission on Accreditation of Healthcare Organizations, have also expressed interest. Indeed, it would appear that certification for hospice nurses has become a "bread and butter" issue not only for nurses but for other segments of the hospice community.
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87
REFERENCES Amenta, M. (1991, November). Characteristics of hospice nurses revisited. Paper presented at the Annual Meeting of the National Hospice Organization, Seat tle, WA. Bene, 8., & Foxhall, M.J. (1991). Death anxiety and job stress in hospice and medical-surgical nurses. The Hospice Journal, 7, 25-41. Fickeissen, J. L. (1990). 56 ways to get certified. American Journal of Nursing, 90, 50-57. Knight, C. F., & Knight, P. F. (1992). Organization factors to consider when developing a certification program for hospice nurses: A Delphi study. 171e Hospice Journal 8(3). (1992, February) Upsurge in 1991 nursing school enrollments. 8(3). Nursing and Health Care, p. 100.
