The International Society of Plastic and Aesthetic Nurses (ISPAN) supports and encourages the attainment and maintenance of specialty nursing certification specific to plastic and aesthetic nursing (ISPAN, 2015). Nursing specialty certification promotes optimal patient outcomes, enhances the quality of health care provided, and is an important benchmark in verifying competence of the provider (Stucky, De Jong, & Wymer, 2020). Specialty certification enhances patient safety by validating that nursing practice is consistent with the standards and recommendations of the professional nursing specialty organization (ISPAN, 2015). Certification also promotes continuing education and supports advanced education (ISPAN, 2015). Certification is linked to the implementation of evidence-based practice, enhanced patient safety, competence, and optimized patient outcomes (ISPAN, 2015). Certification fosters personal growth, career advancement, and professional prestige (ISPAN, 2015). Nursing specialty certification also helps achieve the recommendations of the Institute of Medicine (2011) report, titled The Future of Nursing: Leading Change, Advancing Health, by providing a framework for lifelong learning and assessment of ongoing competency. The ISPAN encourages all registered nurses (RNs) practicing in the field of plastic or aesthetic nursing to obtain certification (ISPAN, 2015).
Certification is promoted by nursing specialty organizations, but evidence supporting a relationship between improved patient outcomes and specialty nursing certification is mixed. In a review of the literature published between 2008 and 2014, Martin, Arenas-Montoya, and Barnett (2015) found eight studies supporting a relationship between nursing specialty certification and the following:
* Lower rates of patient falls (Boltz, Capezuti, Wagner, Rosenberg, & Secic, 2013; Kendall-Gallagher & Blegen, 2009; Lange et al., 2009);
* Lower rates of hospital-acquired infections, including central line-associated bloodstream infections (Boyle, Cramer, Potter, Gatua, & Stobinski, 2014) and methicillin-resistant Staphylococcus aureus infections (Pogorzelska, Stone, & Larson, 2012);
* Decreased odds of failure to rescue (McHugh et al., 2013); and
* Decreased odds of death (Hickey, Gauvreau, Curley, & Connor, 2013; Kendall-Gallagher, Aiken, Sloane, & Cimiotti, 2011; McHugh et al., 2013).
Conversely, in several studies, the authors found there was no association between nursing specialty certification and the following:
* Fewer patient falls (Boltz et al., 2013; Schuelke, Young, Folkerts, & Hawkins, 2014);
* Reduced numbers of pressure injuries (Boltz et al., 2013; Kendall-Gallagher & Blegen, 2009; Krapohl, Manojlovich, Redman, & Zhang, 2010; Schuelke et al., 2014);
* Lessened use of patient restraints (Boltz et al., 2013);
* Fewer medication errors (Kendall-Gallagher & Blegen, 2009; Schuelke et al., 2014);
* Decreased hospital-acquired infections (Kendall-Gallagher & Blegen, 2009; Krapohl et al., 2010; Schuelke et al., 2014); and
* Increased patient satisfaction (Coleman et al., 2009; Schuelke et al., 2014).
Since the review of the literature conducted by Martin et al. (2015), three additional studies have shown an association between nursing specialty certification and improved patient outcomes.
In a study to examine the relationship between national nursing specialty certification rates and changes in total patient fall rates, Boyle, Cramer, Potter, and Staggs (2015) found that, over time, there was a statistically significant relationship (p = .04) between increasing rates of certification and decreasing patient fall rates.
In another study to develop a unit-level inpatient composite nursing care quality performance index, Boyle et al. (2016) found that hospitals with a higher percentage of RNs with national specialty certification had higher Pressure Ulcer and Fall Rate Quality Composite Index scores, allowing for improved evaluation of provider performance and the ability to make comparisons across units and hospitals to support quality improvement.
In addition, Boyle, Bergquist-Beringer, and Cramer (2017) found that hospitals that employed certified wound, ostomy, and continence nurses, certified wound care nurses, and certified wound and ostomy nurses had lower rates of hospital-acquired pressure injuries and improved practices for pressure injury assessment and prevention. The rate of Stage 3 and Stage 4 pressure injuries in hospitals using certified nurses was 0.27% compared with 0.51% in hospitals using noncertified nurses.
Nurses who seek certification are motivated by intrinsic and extrinsic values. Extrinsic values are those that are external to the individual (e.g., professional recognition), whereas intrinsic values are internal to the individual (e.g., feelings of accomplishment). Intrinsic motivators for obtaining certification include a sense of accomplishment, validation of knowledge, professional growth, professional credibility, and professional challenge (Van Wicklin, Leveling, & Stobinski, 2020). Extrinsic motivators include employer recognition, peer recognition, and professional recognition (Van Wicklin et al., 2020).
Obtaining specialty certification may also provide some employment advantages for nurses such as increased marketability, enhanced chances for job promotion, and a higher salary earned. Stromborg et al. (2005) found that 86% of nurse managers prefer to fill open positions with nurses who are certified because of their validated knowledge base (75.5%), commitment to lifelong learning (67.6%), and ability to serve as role models or mentors (51.8%).
In a salary survey of 2,829 perioperative nurses conducted by Bacon and Stewart (2019), 42% (n = 1,188) of the respondents said that certified nurses were paid more than noncertified nurses. Of these respondents, 40% (n = 475) said that the pay adjustment was in addition to base pay, with the median addition being either $1 per hour or 2.5% of base compensation. Another 25% (n = 297) of the respondents said that the compensation was paid as an annual bonus, with the median bonus being approximately $700.
There is no quantitative evidence as to how plastic and aesthetic nurses perceive the value of certification. The aim of this study was to determine how certified and noncertified plastic and aesthetic RNs, who are members of the ISPAN, perceive the value of certification. A secondary study aim was to compare perceptions of nurses who hold a CPSN (Certified Plastic Surgical Nurse), CANS (Certified Aesthetic Nurse Specialist), or both certifications with nurses who do not hold these certifications.
METHODS
This study used a cross-sectional descriptive design with an additional comparative component. The investigation primarily sought to describe respondents' perceptions of the value of the CPSN and CANS certifications measured by an online survey. In addition, respondents were grouped by various attribute variables to determine whether perceptions of the value of certification differed across groups. The attribute independent variables were the surveyed demographic characteristics of the respondents. The dependent variable was the respondents' perceived value of the CPSN and CANS certifications, specifically the respondents' perceptions of the intrinsic and extrinsic values of the CPSN and CANS certifications.
Participants
The ISPAN was incorporated as a nonprofit organization in 1975 (American Nurses Association [ANA] & ISPAN, 2020). The Society is committed to enhancing the quality of nursing care provided to the client undergoing plastic and reconstructive surgery and nonsurgical aesthetic procedures (ANA & ISPAN, 2020). The ISPAN promotes high standards of plastic and aesthetic nursing practice and client care through education, scientific inquiry, analysis, and dissemination of information (ANA & ISPAN, 2020).
In 1989, the Plastic Surgical Nursing Certification Board (PSNCB) was established to promote the highest standards of plastic surgical nursing practice through the development, implementation, coordination, and evaluation of all aspects of the certification and recertification processes (PSNCB, 2020). The PSNCB offers two certifications for plastic and aesthetic nurses: the CPSN, which was first administered in 1991, and the CANS, which was first administered in 2013 (ANA & ISPAN, 2020). The PSNCB collaborates with the Center for Nursing Education and Testing (C-NET) in the development, administration, and evaluation of these certification examinations (ISPAN, 2015). Requirements to sit for the CPSN and CANS certification examinations are listed in Table 1. Currently, a total of 382 ISPAN members hold the CANS certification and 257 members hold the CPSN certification (Hinojosa, 2020).
The ISPAN maintains a database of its members and allows the Associate Executive Director of the Association Management Company to access and send messages to the ISPAN members for data collection of qualifying research studies. The researchers submitted a proposal to the ISPAN Board of Directors and obtained approval to survey ISPAN members about the value of specialty certification. The Associate Executive Director sent the survey to all ISPAN members who accept e-mail blast messages. All survey responses were self-reported by certified and noncertified plastic and aesthetic RNs who are members of ISPAN.
Protection of Human Subjects
The study collected data from human subjects; therefore, before the study was conducted, the study protocol was reviewed by an institutional review board (IRB) accredited by the Association for the Accreditation of Human Research Protection Programs (Western Institutional Review Board, n.d.). The independent IRB determined the study was exempt under Category 2 of the Common Rule for the Protection of Human Subjects (2002), which provides for exemption if the research:
* Involves the use of survey procedures where the participant cannot be identified;
* Does not place the participants at risk of criminal or civil liability; and
* Is not damaging to the participants' financial standing, employability, or reputation.
An independent IRB was used to ensure the exemption status was determined by an impartial authority.
No requirements, other than membership in the ISPAN, were placed on the respondents to be included in the survey. Participation was voluntary and self-selected but may have potentially introduced a level of bias due to ISPAN membership. As shown in Figure 1, ISPAN members indicated their willingness to participate in the survey by reading the survey statement and clicking on a link that directed them to the survey. The participants had the right to discontinue the survey at any time without consequences. The researchers did not offer or provide any incentives for survey participants.
Measures
The survey comprised 27 questions. Fifteen questions (56%) were designed to collect demographic information about the participants. Demographic questions included in the survey collected information about the participant's age, gender, ethnicity, education, work experience, certification status, and length of ISPAN membership. Options for gender and ethnicity were included in the demographic questions because previous surveys about the value of certification have found that the majority of survey participants were White women (Van Wicklin et al., 2020). Demographic information will be used to capture a picture of the nurses participating in the survey and to compare profiles of certified and noncertified nurses.
The demographic questions included in the survey were developed by the primary researcher, who is the first author of the study. Feedback and suggested revisions to the survey were provided by the independent research statistician, who is the second author of the study, the Competency and Credentialing Institute (CCI) Program Coordinator, Governance and Accreditation, CCI), and members of the PSNCB Board of Directors.
The Perceived Value of Certification Tool (PVCT)-12 comprised the remaining 12 questions (44%) of the survey and was used to obtain perceived extrinsic and intrinsic information from the RN participants about the value of certification. The PVCT-12 assesses the value of nursing certification using a 4-point Likert scale with responses of strongly disagree, disagree, agree, and strongly agree. The items are sorted into an extrinsic score (Questions 3, 4, 5, 9, 10, 11; 6 x 4 = 24 points maximum) and an intrinsic score (Questions 1, 2, 6, 7, 8, 12; 6 x 4 = 24 points maximum) and then summed. Per agreement with the CCI, no revisions or changes were made to the PVCT-12.
The PVCT was developed in 2003 by the research and consulting firm of Berlin Sechrist Associates (2003). The PVCT was developed for the Certification Board of Perioperative Nursing (CBPN), now known as the CCI. Although the PVCT was developed for use with RN participants specializing in perioperative nursing, the tool has been used in 18 studies surveying more than 26,000 respondents representing a diversity of nursing specialties to examine the participant's perceived value of specialty certification.
In a recent systematic review of these 18 studies using the PVCT (Van Wicklin et al., 2020), the researchers found that despite the high levels of validity and reliability (Cronbach's [alpha] = 0.94) associated with the PVCT, the participating RNs expressed high levels of agreement and little disagreement with most of the PVCT value statements.
In response to this observation, the CCI conducted a nationwide study to examine the psychometric properties of the original PVCT, which contained 18 items, and compared it with a revised version of the tool containing 12 items, known as the PVCT-12 (Henderson, Leveling, & Stobinski, 2019). The researcher found that the PVCT-12 yielded a measurement model with improved fit and increased the variation in responses. These results suggest that the PVCT-12 has a higher level of construct validity than the original PVCT. The intrinsic and extrinsic items of the PVCT-12 showed an acceptable range of reliability and a stable factor structure (intrinsic: [alpha] = 0.74-0.83; extrinsic: [alpha] = 0.83-0.86), providing evidence of its concurrent validity and support for its use for research examining the perceived value of certification among various groups of nurses.
The survey was built by the CCI Program Coordinator, Governance and Accreditation, CCI, using the SurveyGizmo cloud-based integrated feedback platform technology (Boulder, CO).
Statistical Analyses
The independent research statistician performed the statistical analyses. Descriptive statistics (e.g., absolute and relative frequency, mean, standard deviation, minimum, and maximum) were calculated for various demographic variables including age, gender, ethnicity, education, work experience, certification status, and length of ISPAN membership, as well as for the PVCT-12. Responses to the PVCT-12 value statements were coded as follows: 1 =strongly disagree; 2 =disagree; 3 = agree; and 4 = strongly agree. The scores for each item were summed to calculate intrinsic value, extrinsic value, and total scores for each participant. Intrinsic and extrinsic value subscale scores were analyzed in groups of certified and noncertified participants, as well as across other attribute variables such as education and work experience. In this study, certification status refers to whether participants hold a CPSN, CPSN-R (CPSN-Retired), CANS, or CANS-R (CANS-Retired) certification.
The reliability of the intrinsic and extrinsic value subscales was assessed using both Cronbach's (1951) alpha and McDonald's (1999) omega. Omega reliability estimates in this study should be regarded as more accurate than alpha, given alpha's assumption of essential tau equivalence, which is unlikely to be met by the PVCT-12 (see McNeish, 2018, for a technical description of this issue). The construct validity of the PVCT-12 was analyzed using a multidimensional item response theory (IRT) analysis. Descriptive results for the PVCT-12 and Cronbach's alpha estimates were generated using STATA, Version 15.1 (StataCorp, 2017), whereas the IRT analysis and the estimation of the item loadings for omega calculations were completed in Mplus, Version 8.2 (Muthen & Muthen, 2017).
An independent-samples t test was conducted when comparing PVCT-12 scores from two groups with approximately normal distributions and equal variances. The variables that were analyzed with a t test were intrinsic and extrinsic values by certification status (i.e., certified or not certified) and extrinsic value by receiving a monetary reward for earning certification (i.e., yes or no). A Welch's t test was used when comparing two groups with heterogeneous variances, and a Mann-Whitney U test was conducted when comparing two groups that displayed a violation to normality. More specifically, a Welch's t test was used when analyzing intrinsic and extrinsic values by years with a CANS certification and a Mann-Whitney U test was used when analyzing intrinsic value by receiving a monetary reward for earning certification. An analysis of variance (ANOVA) was performed when intrinsic and extrinsic value scores were compared across three or more groups of participants with approximately normal distributions and equal variances. A significant ANOVA was investigated further with Tukey's honestly significant difference post hoc test to determine which groups significantly differed. ANOVAs were conducted when comparing intrinsic and extrinsic values by age range, ethnicity, years as a plastic or aesthetic nurse, years as ISPAN member, earning a CPSN, CANS, or CPSN and CANS certification, and years with a CPSN certification, as well as for extrinsic value by years as an RN and highest non-nursing degree. In the case of normality violations, a Kruskal-Wallis H test was used instead of an ANOVA for group comparisons, including intrinsic value by ethnicity, highest non-nursing degree, years as an RN, and years as a plastic or aesthetic nurse. A significant Kruskal-Wallis test was followed by a post hoc Dunn's test to elucidate the specific groups that differed. All comparative analyses were conducted using STATA, Version 15.1 (StataCorp, 2017), and results were considered significant at p < .05.
The independent research statistician used STATA, Version 15.1, to conduct an a priori power analysis to determine the necessary sample size to detect differences in intrinsic and extrinsic value scores between participants grouped by various attribute variables (e.g., age, work experience, and certification status). Because the PVCT-12 was very recently developed (Henderson et al., 2019), there was insufficient research to guide the power analysis; therefore, the proposed sample size should be regarded as approximate. Results from the sample used to develop the PVCT-12 (Henderson et al., 2019) were used to approximate the sample size needed for this investigation. Results from the power analysis indicated that, at a confidence level of 95% and a power of 0.80, a sample of approximately 274 respondents would be needed to detect the smallest of the effect sizes expected between groups.
Data Collection
The survey was sent to all ISPAN members who accept blast e-mails on September 3, 2020. Reminders to complete the survey were sent on September 19 and September 24, 2020. Reminders were also posted on the ISPAN Member's Only FaceBook (Menlo Park, CA) page on September 21 and September 28, 2020. The survey was closed on October 3, 2020.
RESULTS
The researchers analyzed the results of the survey in three parts. First, participants' responses to the demographic questions in the survey were analyzed to uncover the descriptive characteristics of the ISPAN sample, with an eye toward the profiles of certified and noncertified participants. Second, the reliability and validity of the PVCT-12 were examined to determine the instrument's appropriateness for the sample of ISPAN members. Third, participants' perceptions of the value of the CPSN and CANS certifications were investigated and compared across groups determined by attribute variables (e.g., certification status, work experience). Following are the results from each of these stages explained in greater detail.
Sample Characteristics
The survey was sent to 1,251 ISPAN members. A total of 225 members (18.0%) agreed to participate in the study. However, five participants left the entire PVCT-12 blank, resulting in a sample of 220 nurses used in the analysis.
As shown in Table 2, the majority of participants were women (n = 213; 97.3%) between the ages of 40 and 69 years (n = 180; 81.8%) who identified themselves as being White or European American (n = 193; 87.7%). Participants most frequently reported having a bachelor's degree (n = 100; 46.1%) as their highest nursing degree, followed by associate (n = 52; 24.0%) and master's (n = 49; 22.6%) degrees. Only 11 (5.1%) participants reported having a doctoral degree in nursing. Of the 220 participants included in the analysis, 115 (52.3%) had a degree in an area other than nursing, most of which were bachelor's degrees (n = 59; 26.8%).
Participants' experience working as an RN ranged from 0 to 4 years (n = 5; 2.3%) to more than 35 years, with the bulk of participants having worked as an RN for 15-24 years (n = 61; 27.8%) or more than 35 years (n = 70; 32.0%). Participants had less experience working as a plastic or aesthetic RN, with 39 (18.0%) having 0-4 years of experience, 75 (34.4%) having 5-14 years of experience, 61 (23.8%) having 15-24 years of experience, and only 21 (9.6%) having more than 35 years of experience. As shown in Table 3, participants reported working in various types of facilities as a plastic or aesthetic nurse including physician's offices (n = 136; 39.2%), ambulatory surgical centers (n = 64; 18.4%), nonsurgical aesthetic centers (n = 55; 15.9%), university medical centers (n = 40; 11.5%), community hospitals (n = 23; 6.6%), aesthetician's offices (n = 17; 4.9%), medical spas (n = 8; 2.3%), and private practices (n = 4; 1.2%).
Relative to ISPAN membership, the most frequent response from participants was that they had been a member of ISPAN for 0-4 years (n = 93; 42.3%) or 5-14 years (n = 52; 32.3%). Only nine (4.1%) participants had been a member for 35-44 years.
Of the 220 participants, 129 (58.6%) were certified, 90 (41.0%) were not certified, and one participant (0.5%) did not report his or her certification status. Among the certified participants, 43 (33.3%) held a CPSN or CPSN-R certification, 36 (27.9%) held a CANS or CANS-R certification, and 50 (38.8%) held both certifications. Participants who held a CPSN or CANS certification most frequently reported having 5-24 years of experience as a plastic or aesthetic nurse (n = 84; 66.1%) and more than 35 years of experience as an RN (n = 51; 39.8%). Most certified participants were between the ages of 60 and 69 years (n = 43; 33.3%) or between the ages of 50 and 59 years (n = 36; 27.9%). The majority of participants who did not hold a CPSN or CANS certification had 0-14 years of experience as a plastic or aesthetic nurse (n = 65; 72.2%) and 5-24 years of experience as an RN (n = 53; 58.9%). Most noncertified participants were between the ages of 40 and 49 years (n = 31; 34.4%) or between the ages of 60 and 69 years (n = 22; 24.4%). The majority of certified participants (n = 104; 78.2%) did not receive a monetary reward (e.g., reimbursement of examination-related costs) for earning their certification. See Table 4 for the types of monetary rewards provided to participants who were compensated for earning a CPSN or CANS certification. Noncertified participants reported the following reasons for not being certified:
* Not required for my position;
* Not enough time to prepare;
* Costs too much;
* Difficulty meeting certification and recertification requirements, especially the requirement of working under a board-certified plastic/aesthetic surgeon;
* Not yet eligible or certification in progress; and
* Inconvenient testing facility locations.
Reliability and Validity of the PVCT-12 in the ISPAN Sample
The intrinsic and extrinsic subscales of the PVCT-12 demonstrate an acceptable to high level of reliability in terms of Cronbach's alpha (intrinsic: [alpha] = 0.76; extrinsic: [alpha] = 0.87) and McDonald's omega (intrinsic: [omega] = 0.86; extrinsic: [omega] = 0.92) in the sample of 220 ISPAN members. Because the PVCT-12 is likely to violate alpha's assumption of essential tau equivalence, alpha can be conceived as the lower-bound estimate of reliability in this study (e.g., Graham, 2006; Miller, 1995) and omega can be regarded as the more accurate reliability estimate.
A multidimensional IRT model was used to examine the model fit of the PVCT-12 and thus the construct validity of the instrument for the sample of ISPAN nurses. Although the comparative fit index (CFI = 0.952) reached an acceptable level of fit (i.e., >= 0.95), the root mean square error of approximation (RMSEA = 0.117) was poor, as it was above what is commonly considered the most relaxed upper limits of measurement model fit (i.e., RMSEA should be no bigger than 0.08; Hooper, Coughlan, & Mullen, 2008). The unsatisfactory RMSEA value suggests that the PVCT-12 may not be the most valid instrument for this sample of ISPAN members. This may be a limitation of the study.
Perceptions of the Value of CPSN and CANS Certifications
As shown in Table 5, the sample of ISPAN members displayed the highest level of agreement with the intrinsic value statements and the lowest level of agreement with the extrinsic value statements. The value statements that participants agreed with the most (i.e., responded with agree or strongly agree) were all intrinsic value statements. These statements included the following:
* Nurses who have obtained a certification feel a strong sense of accomplishment (n = 219; 97.2%);
* Certification validates specialized clinical knowledge (n = 219; 91.2%); and
* Obtaining certification shows that a nurse is committed to the nursing profession (n = 219; 90.4%).
The extrinsic value statement that exhibited the highest level of agreement was "Nurses who have obtained certification receive greater professional recognition from peers" (n = 219; 73.0%). The highest level of disagreement (i.e., participants responded with disagree or strongly disagree) occurred with both intrinsic and extrinsic value statements. These statements included the following:
* Certified nurses generally make more money than noncertified nurses (extrinsic: n = 217; 68.6%);
* Certified nurses are given more professional autonomy than noncertified nurses (extrinsic: n = 218; 60.6%); and
* Obtaining certification is one of the most challenging aspects of the nursing profession (intrinsic: n = 215; 43.7%).
Table 6 displays a breakdown of the PVCT-12 item, subscale (i.e., intrinsic and extrinsic), and total scale means for certified participants, noncertified participants, and all participants. Notably, certified participants had a higher mean score than noncertified participants on every item of the PVCT-12, suggesting that the certified participants perceived greater intrinsic and extrinsic values in the CPNS and CANS certifications than the participants who did not hold either certification. A closer examination of the differences in certified and noncertified participants' intrinsic and extrinsic value scores showed that certified participants reported significantly higher perceptions of the intrinsic (t = 6.24, p < .001) and extrinsic (t = 3.47, p < .001) values of being certified than noncertified participants.
A comparison of participants with only CPSN certifications, only CANS certifications, both CPSN and CANS certifications, and neither certification showed that, on average, participants in all three certification groups scored significantly higher on perceived intrinsic value, F(3, 215) = 14.11, p < .001, than participants who did not hold either certification. Participants who held both certifications had the highest average intrinsic value score (M = 20.04, SD = 2.86), but it was not significantly higher than participants in the only CPSN and only CANS certification groups. An analysis of extrinsic value scores across the four certification status groups showed that, although all three certification groups had a higher mean score than those who were not certified, only the group of participants with both CPSN and CANS certifications (M = 17.06, SD = 3.62) scored significantly higher on extrinsic value than participants who did not hold either certification, F(3, 215) = 5.24, p = .002.
An analysis of the perceived value of certification based on years of experience as an RN showed that participants with more than 35 years of RN experience and participants with 25-34 years of RN experience reported significantly higher, [chi]2 (3) = 10.49, p = .015, perceptions of the intrinsic value of certification than participants with 15-24 years of experience. No significant differences were found in extrinsic value scores across RN experience. Significant differences in the intrinsic, F(4, 215) = 5.95, p = .0001, and extrinsic, F(4, 215) = 2.70, p = .032, values of certification were found with years as an ISPAN member. Specifically, participants who had been a member of ISPAN for 35-44 years reported significantly higher perceptions of intrinsic value than groups with 0-4 years and 5-14 years of ISPAN membership. In addition, participants with 25-34 years of ISPAN membership reported significantly higher perceived intrinsic value than the group with 0-4 years of membership. Perceptions of extrinsic value in the group of participants with 35-44 years of ISPAN membership were found to be significantly higher than the group with 0-4 years of membership.
When participants grouped by years with a CPSN certification and years with a CANS certification were compared, significant differences were only found in the extrinsic value scores of participants grouped by years with a CANS certification (Welch's t = -2.44, p = .018). More specifically, participants who held a CANS certification for 5-7 years reported significantly higher perceptions of the extrinsic value of certification than participants who held a CANS certification for 0-4 years. No significant differences in perceptions of intrinsic or extrinsic value were found with age range, ethnicity, education, years of experience as a plastic or aesthetic nurse, and receiving a monetary reward for certification.
DISCUSSION
The ISPAN supports and encourages the attainment and maintenance of specialty nursing certification specific to plastic and aesthetic nursing (ISPAN, 2015). Nursing specialty certification may help validate competence of the provider, promote optimal patient outcomes, and enhance the quality of nursing care provided (Stucky et al., 2020). Nurses who seek certification are motivated by intrinsic values that are internal to the individual (e.g., feelings of accomplishment) and extrinsic values that are external to the individual (e.g., professional recognition).
The aim of this study was to determine how certified and noncertified plastic and aesthetic RNs, who are members of the ISPAN, perceive the value of certification. A secondary study aim was to compare perceptions of nurses who hold a CPSN, CANS, or both certifications with nurses who do not hold these certifications. The results of this study showed that certified participants had a higher mean score than noncertified participants on every item of the PVCT-12, suggesting that certified participants perceived greater intrinsic and extrinsic values in certification than the participants who did not hold either certification.
Study participants had the highest level of agreement with the intrinsic value statements and the lowest level of agreement with the extrinsic value statements. The greatest level of participant agreement was with the perceived intrinsic value statements that earning certification provided the nurse with a strong sense of accomplishment, validated their clinical knowledge, and demonstrated their commitment to the nursing profession. The greatest level of participant agreement was with the perceived extrinsic value statement that earning certification provided professional recognition from peers.
The greatest level of participant disagreement was with the perceived intrinsic value statement that obtaining certification is one of the most challenging aspects of the nursing profession. The greatest level of participant disagreement was with the perceived extrinsic value statement that certified nurses have more professional autonomy and make more money than noncertified nurses.
When compared with noncertified participants, certified participants scored significantly higher on perceived intrinsic value. Participants who held both CPSN and CANS certifications had the highest average intrinsic value score, but it was not significantly higher than participants in the only CPSN and only CANS certification groups. When compared with noncertified participants, certified participants also scored higher on perceived extrinsic value; however, only the group of participants with both CPSN and CANS certifications scored significantly higher on extrinsic value than noncertified participants.
Limitations
One potential limitation of this study is the large RMSEA value (i.e., 0.117) for the PVCT-12. This result encouraged the researchers to examine the psychometric properties of the PVCT-12 further. A closer investigation of the items (e.g., factor loadings, item communalities, and residual variance of items) revealed that some PVCT-12 items were not performing well. In addition, an examination of the subscale distributions showed that the sample of ISPAN members exhibited a high level of agreement with the intrinsic value items, as the scores on this distribution were positively skewed. It is possible that the positive skew, which has been identified in previous investigations of the original 18-item PVCT (see Van Wicklin et al., 2020), and the unsatisfactory functioning of some items are possible explanations for the high RMSEA value. With that said, the PVCT-12 is a new instrument and additional research is needed to understand its appropriateness for different samples of nurses.
Another possible limitation of this investigation is that the final sample of 220 participants was smaller than the sample size identified in the power analysis (i.e., 274). It is hard to say for sure that the sample size is a true limitation, given the lacking research available to base the power analysis on, but it is possible that the sample of 220 ISPAN members was too small to detect some smaller effect sizes.
The low response rate (18%) that resulted when sampling for participants for the study marks another aspect of this investigation that is a potential limitation. Among the 1,251 ISPAN members who were sent the survey, only 225 (18%) agreed to participate and five of those individuals left the entire PVCT-12 blank, leaving only 220 participants (17.6%) to represent the population targeted in the study. This low response rate introduces concerns that conclusions drawn in the study may not hold for the vast majority of ISPAN members who did not participate in the study, as nonparticipants may have different attributes and perceptions of certification that the study was not able to capture. As such, it is possible that the low response rate biased the sample's representation of the target population and thus jeopardized the generalizability of the study's results to all ISPAN members. Although it is possible that the study results are valid for the average ISPAN member, more research is needed on ISPAN members, or more broadly plastic and aesthetic nurses, to paint a fuller picture of perceptions of the value of specialty certification among this population of nurses.
CONCLUSION
More than half of the sample of ISPAN members were certified (n = 129; 58.6%), but only 29 participants (22.5%) received a monetary reward for earning CPSN or CANS certification. Notably, the extrinsic value statements of the PVCT-12 were the least endorsed by the participants. Considering the barriers to certification that were noted by noncertified participants in the study (e.g., high costs, inconvenient testing facilities, strict employment requirements), health care and nursing certification organizations should consider offering additional support and providing more extrinsic rewards for nurses who earn specialty certification. Added support and recognition for nurses, both throughout and after the certification process, may be what is necessary to increase the proportion of certified nurses.
ACKNOWLEDGMENTS
Funding for use of the PVCT-12, IRB, and statistical analysis was provided by the ISPAN. The authors thank Jim Stobinski, Chief Executive Officer, Competency and Credentialing Institute, Denver, CO, for his assistance in undertaking this survey project, and Benjamin Dennis, Program Coordinator, Governance and Accreditation, Competency and Credentialing Institute, for developing the survey. The authors also thank Heather MacLean, Associate Executive Director, PRRI Association Management Company, Beverly, MA, for her assistance with sending the survey to the ISPAN membership, and the ISPAN Board of Directors, for their support of this research project.
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