You must access the following article to answer the questions: Boyle, D. K., & Thompson, S.A. (2020). CMSRNs' continuing competence methods and perceived value of certification: A descriptive study. MEDSURG Nursing, 29(4), 229-254. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=145282314&site=eds-live&scope=site Locate the literature review section. Summarize using your own words from one of the study/literature findings. Be sure to identify which study you are summarizing. Discuss how the author’s review of literature (studies) supported the research purpose/problem. Share something that was interesting to you as you read through the literature review section. Describe one strategy that you learned that would help you create a strong literature review/search for evidence. Share your thoughts on the importance of a thorough review of the literature. CMSRNs’ Continuing Competence Methods and Perceived Value of Certification: A Descriptive Study Nursing specialty certification builds on nursing licensure. It acts as a mechanism for validation or formal recognition by documenting individual nurses’ knowledge, skills, and abilities spe- cific to their specialty. To become certified, nurses are required to meet predetermined eligibility crite- ria and achieve standards identified by a nursing specialty, including sufficient practical experience and passing a certification examination that provides external validation of knowledge and judgment. The intended outcome of certification in nursing is to validate compe- tence with the overall goal of improving safety, quality of care, and health outcomes for people who use healthcare services. (Chappell et al., 2019). For the Certified Medical-Surgical Registered Nurse (CMSRN®) certifi- cation, initial eligibility criteria are registered nursing licensure, 2 years of practice in a medical-sur- gical setting (may include clinical, management, or education), and 2,000 hours of medical-surgical practice in the past 3 years. Eligible candidates earn the cre- dential by passing an exam (Medical-Surgical Nursing Certifi- cation Board [MSNCB], n.d.). To recertify, CMSRNs must continue to practice in a medical-surgical setting and provide evidence of continuing competence in the specialty (MSNCB, 2019). Continuing competence is “the ongoing commitment of a regis- tered nurse to integrate and apply the knowledge, skills, and judg- ment with the attitudes, values, and beliefs required to practice safely, effectively, and ethically in a desig- nated role and setting” (Di Leonardi & Biel, 2012, p. 350). The Con- tinuing Competence Task Force (Hospice and Palliative Creden- tialing Center [HPCC], 2011) estab- lished this definition to guide estab- lishment of meaningful recertifica- tion requirements in nursing. MSNCB (2012), which administers the CMSRN credential, has en- dorsed the definition. MSNCB spec- ifies an accepted set of methods of evidence of continuing competence for CMSRN recertification. Exam- ples are continuing nursing educa- tion (CNE) activities, advanced car- diovascular life support, profession- al publications, and evidence-based practice projects (MSNCB, 2019). The Institute for Credentialing Excellence (ICE) provides a compre- hensive list of methods for demon- strating continuing competence. Examples listed by ICE, but not accepted currently by MSNCB, Diane K. Boyle Sarah A. Thompson Specialty nursing certification is validation and formal recognition of nurses’ knowledge, skills, and abilities. The intrinsic and extrinsic reasons nurses value Certified Medical-Surgical Registered Nurse certification, as well as facilitators to and barriers of certification, are discussed. A combination of intrinsic and extrinsic facilitators is essential for certifying programs and healthcare organizations to use in achieving higher numbers of specialty-certified nurses. Instructions for CNE Contact Hours MSN J2012 Continuing nursing education (CNE) contact hours can be earned for completing the evaluation associated with this article. Instructions are available at amsn.org/journalCNE Deadline for submission: August 31, 2022 1.4 contact hours Diane K. Boyle, PhD, RN, FAAN, is retired Professor, Fay W. Whitney School of Nursing, University of Wyoming, Laramie, WY. Sarah A. Thompson, PhD, RN, FAAN, is Dean and Professor, Sinclair School of Nursing, University of Missouri, Colombia, MO. Funding: Research reported in this publication was supported by the Medical-Surgical Nursing Certification Board. The content is solely the authors’ responsibility and does not necessarily represent the official views of the Medical-Surgical Nursing Certification Board. July-August 2020 • Vol. 29/No. 4 229 Background The Medical-Surgical Nursing Certification Board is reviewing strategies and requirements for demonstrating continuing competence for the Certified Medical-Surgical Registered Nurse (CMSRN®) credential. Aim Determine current methods of continuing competence, facilitators and barriers of continuing competence, and perceptions of the value of certi- fication by CMSRNs. Method A national online survey was disseminated to CMSRNs who were 3-5 years after initial certification or 3-5 years after recertification. Results CMSRNs mainly used continuing education to demonstrate continuing competence. Certificants highly valued intrinsic aspects of certification, such as personal satisfaction and accomplishment. The extrinsic benefit of increased marketability was valued highly as well. Main facilitators of continuing competence and certification were reimbursement of costs and paid time off for continuing education and conferences. Main barri- ers were costs, lack of paid time off, and tracking education for various recertification requirements. Limitations and Implications A convenience sample and low response rate limit generalizability of results. A combination of intrinsic and extrinsic facilitators is important for certifying organizations and healthcare leaders to use to achieve high- er numbers of specialty-certified nurses. In addition, certifying organiza- tions may need to improve mechanisms to assist certificants as continu- ing competence requirements for recertification change. Conclusion Intrinsic and extrinsic values of certification, as well as the facilitators of and barriers to certification, have remained stable over time and across various types of specialty certifications. Future research should examine specific levels and types of certification needed to achieve optimum out- comes. include obtaining a new certifica- tion in a related field, simulations, and oral, written, or performance competency assessments (Plaus et al., 2013). To assure the continuing compe- tence of specialty certified nurses, Di Leonardi and Biel (2012) asserted certification and recertification pro- grams should employ periodic indi- vidual competency assessments and subsequent development of indi- vidualized learning plans to address learning needs noted in the evalua- tions. Consequently, some nursing specialty certification programs responded by pioneering recertifica- tion requirements that include competency assessments and tai- lored learning strategies (HPCC, n.d.; Oncology Nursing Certifica- tion Corporation, 2020). Purpose MSNCB is reviewing strategies and requirements to demonstrate continuing competence for nurses who hold the CMSRN credential. However, no decisions have been made about specific changes in requirements (T. Hinkley, personal communication, August 26, 2019). To inform these decisions and the general ongoing dialogue about continuing competence, MSNCB conducted a national online survey to determine CMSRNs’ methods of continuing competence, facilitators and barriers to continuing compe- tence and certification, and percep- tions of the value of certification. Review of the Literature Literature was identified via PubMed and CINAHL for three con- tent areas for 2015-January 2020. For continuing competence, search terms were continuing competence, continuing competency, continued competence, continued competency, continuing competence methods, and continuing competence requirements. For the value of certification, search terms were the value of certification, perceived value of certification, and nursing. For facilitators and barriers, search terms were certification facili- tators, certification barriers, certifica- tion benefits, and nursing. Continuing Competence Di Leonardi and coauthors (2020) reported a comprehensive literature review on continuing competence that included 50 arti- cles published since 2012. The review was preliminary work for purposes of revisiting the earlier definition of continuing compe- tence given in this article’s intro- duction (Di Leonardi & Biel, 2012). Literature findings were reported in four categories: identifying specific competencies, validating compe- tencies, international competency assessment, and competencies in disciplines other than nursing. Review findings in the category of validating competencies were rel- evant to the current study. The cat- egory focused on how proficiencies required for specific credentials such as certification can be “validat- ed and revalidated periodically in a defensible yet financially and logis- tically feasible way” (Di Leonardi et al., 2020, p. 19). Attendance at for- mal or informal educational ses- sions was one of the most common methods for maintaining continu- 230 July-August 2020 • Vol. 29/No. 4 CMSRNs’ Continuing Competence Methods and Perceived Value of Certification: A Descriptive Study ing competence. Some evidence supported educational sessions as a method to increase knowledge and perceived competence. Alternately, the review reported professionals might attend educational courses that are convenient and affordable, but not of high quality or not in the area of greatest learning need. Attendance at educational pro- grams does not ensure changes in practice. Authors suggested partici- pants may not “be able to under- stand, retain, or use the informa- tion that was provided” (p. 19). Other continuing competence methods used for recertification included completion of a written examination, documentation of practice hours in the specialty, scholarship through publication and professional presentation, port- folios, and performance of a formal 360-degree assessment (Di Leonardi et al., 2020). Although simulation (patient and virtual) is accepted as a teaching tool, less evidence existed for using simulation as a method for evaluating continuing compe- tence in credentialing and certifica- tion. The Value of Nursing Specialty Certification Whitehead and colleagues (2019) reported a systematic review of the relationship between specialty nurs- ing certification and patient, nurse, and organizational outcomes. The review included 41 articles pub- lished 2000-2018. Nurse-related outcomes were reported in the cate- gories of personal and professional incentives, knowledge and skills, job satisfaction, organizational commitment, empowerment, and confidence. Review findings in the nurse out- come categories of personal and pro- fessional incentives were relevant to the current study (Whitehead et al., 2019). In 13 studies representing a variety of specialty areas, respon- dents completed the Perceived Value of Certification Tool (PVCT), which measures the value of certifi- cation in two domains: intrinsic and extrinsic rewards, specified as per- sonal and professional incentives respectively by Whitehead and coauthors. The three highest-rated intrinsic rewards for certified nurses were consistent across all 13 studies. These were enhances feeling of person- al accomplishment, provides personal satisfaction, and validates specialized knowledge. Based on seven of the 13 studies, the average agreement rate was 98.45%, 97.93%, and 97.13%, respectively. Among the PVCT extrinsic values, Whitehead and colleagues (2019) reported the three highest-scoring statements were certification pro- motes recognition from peers, promotes recognition from other health profes- sionals, and promotes recognition from employers. The average levels of agreement were 85.96%, 78.68%, and 84.45%, respectively. Across studies in the review, extrinsic fac- tors scored lower than intrinsic fac- tors, but were still high, with one exception. Increases salary consistent- ly had the lowest average of 41.1%. Since the review by Whitehead and coauthors (2019), two studies on the perceived value of certifica- tion have been published. Barbe and Kimble (2018) surveyed 92 nursing academic faculty members who were certified nurse educators. The three highest-rated intrinsic items were validates specialized knowledge (99%), enhances feelings of personal accomplishment (98.9%), and provides personal satisfaction (97.9%). For extrinsic items, the three highest scored items were pro- motes recognition from peers (91.3%), increases marketability (80.4%), and promotes recognition from employer (76.1%). Increases salary was the lowest scoring item (13.1%). Garrison and associates (2018) surveyed 143 specialty-certified nurses at one midwestern commu- nity hospital. The two highest-scor- ing intrinsic items were enhances feeling of personal accomplishment (97.2%) and validates specialized knowledge (97.2%). Promotes personal satisfaction, enhances professional credibility, and provides professional challenge all received 96.5% agree- ment. The three highest-scoring extrinsic factors were increases mar- ketability (95.1%), promotes recogni- tion from employers (95.1%), and increases salary (88.1%). The intrinsic value findings from Barbe and Kimble (2018) and Garrison and coauthors (2018) mir- rored the conclusions of the system- atic review by Whitehead and col- leagues (2019). However, unlike the work by Whitehead and coauthors, increases marketability was among the top three extrinsic values in both studies and increases salary was among the top three in the Garrison study. Facilitators and Barriers of Nursing Certification In the literature search, only three studies were found that reported barriers to certification. None discussed facilitators other than the perceived value of certifi- cation. Therefore, two large-sample classic studies that include facilita- tors and barriers of certification are included in this review. In the first study, the American Board of Nursing Specialties (ABNS) surveyed 8,615 certified nurses from 20 ABNS member organizations (Niebuhr & Biel, 2007). MSNCB conducted a second study of 1,383 MSNCB certi- ficant respondents (Haskins et al., 2011). Both the ABNS (Niebuhr & Biel, 2007) and MSNCB (Haskins et al., 2011) studies found the top three facilitators for obtaining and main- taining certification were reim- bursement for exam fees, renewal fees, and continuing education; recognition such as having creden- tials listed on nametag, publication of name in institutional newsletter, and name on plaques; and bonuses and increases in salary. The top bar- riers identified included the cost of the examination, lack of institu- tional support, and lack of time and access to materials to prepare for the exam. No response percentages were reported in either study. Three recent studies explored barriers to nursing certification, including those by Barbe and Kimble (2018) and Garrison and coauthors (2018) as described previ- ously. Also, McLaughlin and Fetzer (2015) surveyed 305 nurses in two New England community hospitals to determine the perceived value of certification and barriers to certifi- July-August 2020 • Vol. 29/No. 4 231 cation; results for the perceived value of certification were included in the systematic review by Whitehead and colleagues (2019). Barbe and Kimble (2018) found the top three barriers were lack of time (38.5%), cost (17.2%), and no desire/no interest (11.8%). Garrison and associates (2018) identified not enough time (36%), cost of the exam (30%), and not yet eligible (28%) as the top three barriers. The top three barriers identified by McLaughlin and Fetzer (2015) were lack of institutional reward (39.1%), inadequate compensation for certi- fication (37.1%), and cost of the examination (33.7%). Ethics Approval for the project protocol was obtained from the University of Wyoming Institutional Review Board. Although MSNCB sent the recruitment emails, only the study researchers had access to the online survey account and other research files. The cover page of the online survey contained the consent form. Respondents indicated they had read the consent form and volun- tarily agreed to participate by click- ing on the link that continued to the survey. Respondents were offered a chance to win one of 20 $50 gift certificates as an incentive to complete the survey. Interested respondents were given a link to send their email addresses to the research team. Twenty participants were chosen at random to receive the gift certificate at the close of the survey. Sample Selection Because the CMSRN credential is valid for 5 years (MSNCB, 2019), the target population was nurses 3- 5 years after initial certification or recertification. These certificants were more likely to be gathering and submitting evidence of contin- uing competence for recertification. At the time of the survey, the total population was 16,195 CMSRNs; all were invited to participate. Design and Method Survey Construction and Content Survey items were constructed by the researchers in collaboration with the MSNCB staff. The survey was pilot-tested with a convenience sample of registered nurses. Pilot survey feedback regarding the wording of items and instructions was incorporated into the final sur- vey. Items in the online survey were categorized under the following variables. Methods of maintaining continuing competence. Two sources for ongoing competence methods were used. 1. The CMSRN Recertification Guide (MSNCB, 2019) was used to iden- tify methods currently allowed by MSNCB for maintenance of continuing competence and recertification. Each method was listed, and respondents indicated if they had used the technique. 2. The ICE document Methods for Ensuring Continuing Competence (Plaus et al., 2013) was used to identify other methods not cur- rently accepted by MSNCB. These methods could be ap- proved for evidence of continu- ing competence and recertifica- tion by MSNCB. Survey respon- dents were asked to indicate which of ICE-identified methods they would like to have accepted for evidence of continuing com- petence by the MSNCB. Perceived value of certification. The perceived value of certification was measured by the 18 value state- ments (items) of the Perceived Value of Certification Tool© (PVCT©) (Competency and Credentialing Institute [CCI], n.d.; Sechrist & Ber- lin, 2006). The value statements are divided into two domains: intrinsic rewards (12 value statements/items) and extrinsic rewards (6 value state- ments/items). Intrinsic rewards are “motivators internal to an individ- ual and linked to personal develop- ment and self-concept values.” In contrast, extrinsic rewards are “external to an individual and defined by others” (Niebuhr & Biel, 2007, p. 177). Respondents indicat- ed their level of agreement or dis- agreement with each PVCT state- ment on a 4-point Likert-type scale (1=strongly agree, 4=strongly disagree). The reliability and validity of the PVCT have been established (CCI, n.d.; Sechrist & Berlin, 2006). In the current study sample, coefficient alpha for the entire PVCT was 0.95, which compares to 0.92 reported by CCI (n.d.) and 0.93 reported by Haskins and coauthors (2011). Facilitators and barriers to achieve- ment of certification and continuing competence. Items were constructed from a literature review of facilita- tors of and barriers to achievement of certification and continuing competence. Survey respondents indicated their level of agreement or disagreement with each facilita- tor or barrier on a 4-point Likert- type scale (1=strongly agree, 4=strong- ly disagree). Survey Procedures A modified Dillman’s Tailored Design Survey Method (2000) was used to recruit eligible CMSRN cer- tificants. Steps included the follow- ing: (a) deployment email with a study explanation and the survey link, (b) 2-week reminder email with the survey link, (c) 4-week reminder email with the survey link, and (d) final 6-week reminder email with the survey link. The sur- vey closed at 8 weeks following deployment. Findings Response Rate Of 16,195 CMSRN certificants in- vited to participate in the survey, 1,167 completed the survey (response rate 7.2%). Participant Characteristics The typical respondent was fe- male (93.8%, n=990), held a bacca- laureate degree in nursing (52.4%, n=554), had 6-15 years of experi- ence as a medical-surgical nurse (43.7%, n=463), and was age 40-59 (53.8%, n=566). The primary roles of respondents included clinical nurse (61.5%, n=651), unit manager (10.7%, n=113), hospital educator (5.9%, n=62), and academic faculty 232 July-August 2020 • Vol. 29/No. 4 CMSRNs’ Continuing Competence Methods and Perceived Value of Certification: A Descriptive Study TABLE 1. Methods for Maintaining Continuing Competence MSNCB-Accepted Methods % Using this Method CNE activities 92.8 CME when content is applicable to nursing 75.3 ACLS 58.3 Preceptorship and mentoring 56.7 Academic courses 53.3 Presentations for academic courses and CNE credit 35.1 Research and EBP projects 29.0 Member of a national nursing organization board or national committee chair 22.9 Conference poster presentations 21.0 Professional publishing 13.6 Multimedia program development 9.4 Test development/item writing for MSNCB 3.7 CMSRN Recertification Committee member 3.0 Other Potential Methods* % Who Would Like Method Accepted Maintaining certification in a related field 88.9 Obtaining certification in a related field 85.6 Independent study 76.7 Engaging in professional advocacy 73.7 Clinical simulations 72.2 Self-assessment performance 70.1 Self-assessment written 67.8 Test development/item writing for related certification boards 61.8 Self-assessment oral 39.4 ACLS = advanced cardiovascular life support, CME = continuing medical education, CMSRN = certified medical-surgical registered nurse, CNE = continuing nursing education, EBP = evidence-based practice, MSNCB = Medical-Surgical Nursing Certification Board *Institute for Credentialing Excellence (Plaus et al., 2013) member (5.1%, n=54). Most were employed in an inpatient acute set- ting (73.2%, n=774). Many respon- dents were employed in a Magnet® (43.9%, n=462) or Pathway to Excellence® (8.7%, n=92) facility. Continuing Competence Methods Currently Used by CMSRN Certificants Of the continuing competence methods accepted by MSNCB, survey respondents indicated they most fre- quently used CNE (92.8%, n=1,080) and continuing medical education (CME) applicable to nursing (75.3%, n=876). See Table 1 for MSNCB- accepted methods for maintenance of continuing competence in the order of highest to lowest percent- age of use. Other Desired Methods of Continuing Competence Table 1 also lists other potential methods of continuing competence suggested by ICE (Plaus et al., 2013), but not accepted currently by MSNCB. Obtaining (85.5%, n=977) and maintaining (88.9%, n=1,013) certification in a related field were the most highly desired alternative methods for evidence of continuing competence. Facilitators of and Barriers to Continuing Competence and Certification The top three facilitators of con- tinuing competence and mainte- nance of certification for CMSRNs were it’s fun to learn (98.3%, n=1,087), reimbursement for attend- ing continuing education courses and July-August 2020 • Vol. 29/No. 4 233 TABLE 2. Top 10 Facilitators and Barriers to Continuing Competence Facilitators % Strongly Agree/Agree Fun to learn 98.3 Reimbursement for attending continuing education courses and conferences 98.2 Personal sense of professionalism 98.2 Availability of continuing education in specific interest area 97.9 Employing organization encouragement 97.7 Keep me current with latest advancements 97.5 Employer values professionalism for my role 97.5 Paid time off for attending continuing education courses and conferences 97.2 Reimbursement for academic courses 97.1 Availability of continuing education in employing organization 97.1 Barriers % Strongly Agree/Agree Cost 84.0 Making sure continuing education fulfills needed requirements 78.9 Lack of paid time off 74.8 Tracking continuing education for various requirements 71.0 Lack of access to conferences 66.0 Lack of employing organization resources 64.9 Lack of rewards 64.8 Lack of recognition 62.4 Lack of organizational/managerial support 62.4 Time consuming 61.2 conferences (98.2%, n=1,086), and personal sense of professionalism (98.2%, n=1,084). The top three bar- riers for CMSRNs were cost (84%, n=899), making sure continuing edu- cation fulfills needed requirements (78.9%, n=845), and lack of paid time off (74.8%, n=800). Table 2 lists 10 of the highest rated facilitators of and barriers to continuing compe- tence with respective affirmation rates. Perceived Value of Certification to CMSRN Certificants The three intrinsic value state- ments with the highest affirmation rates were provides personal satisfac- tion (97.8%, n=1,034), enhances feel- ing of personal accomplishment (97.6%, n=1,035), and provides evi- dence of professional commitment (97%, n=1,023). The lowest ranking intrinsic value item was enhances professional autonomy (85.5%, n=871). The three extrinsic value statements with the highest affirma- tion rates were increases marketability (88.8%, n=898), promotes recognition from peers (84.1%, n=865), and pro- motes recognition from employers (83.6%, n=869). The lowest rated statement overall was increases salary (46.3%, n=475). Except for the extrinsic value statement of increases marketability, all intrinsic value statements had higher affirmation rates than the extrinsic statements. Table 3 lists the value statements of the PVCT and respective affirmation rates by CMSRN respondents. Discussion Data indicate CMSRNs mainly use CNE and CME (when relevant to nursing) to demonstrate continuing competence. The findings are consis- tent with findings of Di Leonardi and coauthors (2020). However, heavy reliance on continuing educa- tion may call into question if CMSRN practice is changed as a result. Respondents indicated they are interested in using continuing com- petence methods beyond those accepted by MSNCB. A large pro- portion of CMSRN certificants would like obtaining and maintain- ing certification in a related field to be accepted as evidence of continu- ing competence. Respondents also indicated high interest in methods 234 July-August 2020 • Vol. 29/No. 4 CMSRNs’ Continuing Competence Methods and Perceived Value of Certification: A Descriptive Study TABLE 3. Rates of Affirmation for Perceived Value of Certification Tool® Statements Intrinsic Value Statements % Strongly Agree/Agree Provides personal satisfaction 97.8 Enhances feeling of personal accomplishment 97.6 Provides evidence of professional commitment 97.0 Validates specialized knowledge 96.7 Indicates professional growth 96.2 Provides professional challenge 95.7 Enhances professional credibility 94.9 Indicates attainment of a practice standard 94.8 Enhances personal confidence in clinical abilities 93.7 Indicates level of clinical competence 92.3 Provides evidence of accountability 91.1 Enhances professional autonomy 85.5 Extrinsic Value Statements % Strongly Agree/Agree Increases marketability 88.8 Promotes recognition from peers 84.1 Promotes recognition from employers 83.6 Promotes recognition from other health professionals 78.6 Increases consumer confidence 75.8 Increases salary 46.3 such as clinical simulations and assessments (performance or writ- ten). Results suggest CMSRNs may be open to periodic individual com- petency assessments with resulting targeted learning plans. Current findings are mostly con- sistent with other literature (Barbe & Kimble, 2018; Garrison et al., 2018; Whitehead et al., 2019). The two most highly rated intrinsic value statements remained the same: provides personal satisfaction and enhances feeling of personal accomplishment. However, the third- highest rated item in this study was provides evidence of professional com- mitment rather than validates special- ized knowledge, which was a close fourth. Extrinsic values of recogni- tion from peers and employers were among the top three in the present study. However, current study respondents rated increases mar- ketability as the highest extrinsic value; this was not in the top three extrinsic values in the systematic review by Whitehead and col- leagues (2019). Marketability was rated in the top three in studies by Barbe and Kimble (2018) and Garrison and coauthors (2018). Facilitators and barriers of certifi- cation and continuing competence are similar to previous studies. Paid time off and reimbursement for attending continuing education courses and conferences are consis- tently among top facilitators. In the current study, additional top facili- tators were identified as fun to learn and keeping current with the latest advancements. Cost, lack of institu- tional rewards and support, and lack of access to continuing educa- tion courses were among top barri- ers across all studies. Respondents in the current survey reported an additional top barrier: making sure continuing education fulfills recer- tification requirements. Limitations Study participants were a con- venience sample of CMSRNs and may not be representative of all cre- dential holders. The survey re- sponse rate was low despite using Dillman’s (2000) method. Research- ers were unable to know how many individuals received or opened the recruitment email; determination of the response rate thus is not accurate. Budget constraints pre- vented offering an incentive to everyone who participated, which might have increased the response rate. Survey length may have de- terred potential respondents from completing the survey, or from maintaining concentration or inter- est during completion. Recommendations for Future Research As Whitehead and associates July-August 2020 • Vol. 29/No. 4 235 The financial burden to individual nurses is the most frequently cited barrier to certification. (2019) argued, to understand the cost and value of nursing certifica- tion better, “models of lifelong nurs- ing education and training must include evaluation and determina- tion of the specific levels of certifica- tion and types of certification that are absolutely needed to achieve optimum patient, nursing, and orga- nizational outcomes relative to the investment required” (p. 9). To that end, existing databases such as the National Database of Nursing Quality Indicators® (NDNQI®) could be used to examine these authors’ recommendations. NDNQI collects unit-level data that include specific nursing certifications held by staff and a variety of patient (e.g., injury falls, pressure injuries, healthcare- acquired infections) and nursing outcomes (e.g., job satisfaction, turn- over). Also, further investigation using the PVCT might not be war- ranted because of the lack of variabil- ity of findings in studies using the PVCT. Instead, a significant revision of the PVCT is needed to facilitate more meaningful variation in the identification of intrinsic and extrin- sic rewards for certification. Nursing Implications Healthcare Organizations The financial burden to individ- ual nurses is the most frequently cited barrier to certification. Health- care leaders who encourage the attainment of specialty certification need to provide some compensa- tion, such as reimbursement for cer- tification expenses, salary increases, bonuses, and paid time off for certi- fication-related activities. Further, to boost the extrinsic value of spe- cialty certification, recognition from others is valued. Organiza- tional leaders can provide recogni- tion, for example, by putting cre- dentials on nametags, publishing names of certificants in the organi- zational newsletter, and placing plaques with certificant names in respective units. Certification Programs Findings may guide MSNCB and other nursing certification pro- grams in determining what contin- uing competence methods to allow. Also, given the impetus to incorpo- rate strategies such as individual competency assessments and indi- vidualized learning plans to address identified learning needs, certifica- tion programs might need to improve mechanisms to assist certi- ficants. These mechanisms may include providing specific guidance for certificants when developing strategies and selecting appropriate learning opportunities, including encouraging more methods other than continuing education where possible. Tracking various recertifi- cation requirements and ensuring selected learning activities fulfill needed requirements were among the top barriers to maintaining con- tinuing competence and recertifica- tion. Certification programs might need to improve online tracking mechanisms and provide more guidance and specificity about recertification requirements. Medical-Surgical Nurses Medical-surgical nurses, certified and noncertified, are encouraged to become involved in the Academy of Medical-Surgical Nurses (AMSN) as their professional specialty organiza- tion to facilitate lifelong continuing competence. In particular, CMSRNs can engage with AMSN and MSNCB to provide input into recertification requirements, clarity of the require- ments, and support mechanisms needed to maintain specified levels of medical-surgical nursing knowl- edge and skills throughout their professional careers. Conclusion The intrinsic and extrinsic rea- sons that nurses value certification, as well as the facilitators to and bar- riers of certification, have remained stable over time. A combination of intrinsic and extrinsic facilitators is essential for certifying programs and healthcare organizations to use in achieving higher numbers of spe- cialty-certified nurses. 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While this is only a partial health history, summarize in 3 -5 pages the information you gathered. Also, answer the following questions:Was the person willing to share the information? If they were not, what did you do to encourage them?Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?How comfortable were you taking a health history?What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.Your assignment must have accurate spelling and grammar.Book: Physical Examination and Health assessment 8th edition