Organizational culture and roles in promoting nurse specialty certifications: A qualitative study in the United States

Abstract

Objectives

Nursing specialty certification validates nurses’ mastery of specialty knowledge in disease management, education, or leadership above entry-level education and licensing. Research suggests direct relationships between nursing certifications and patient care quality. However, nurses’ specialty certification rates are still low. This study aims to better understand nurses’ perceptions of the facilitators and barriers in promoting nurses’ desires and ability to obtain specialty certifications, which exclude advanced nursing practice roles, such as nurse practitioner or nurse midwife.

Methods

This qualitative descriptive study took place virtually across the United States from May 2022 to September 2022. The study sample was a nested sample of a large national survey study. Among the nurses agreeing to be interviewed, a purposive sampling method was used to achieve maximum variation in diversity, such as years as a nurse, race, ethnicity, and certification status. Information saturation was used to gauge the sample size. Data were collected via in-depth virtual face-to-face interviews. The coding process was based on Colaizzi's method of data analysis.

Results

Twenty nurses participated in the study. Five major themes emerged related to organizational culture and strategies to foster nurse specialty certifications. The five organizational strategies included 1) sharing resources, 2) a culture of ownership and a sense of belonging, 3) mentorship and role modeling, 4) recognizing nurses’ efforts and accomplishments, and 5) cultivating a sense of meaning, purpose, and support.

Conclusions

The findings indicate that organizational culture and leadership significantly promote continuing learning environments. Organizations need to develop an organizational culture that promotes nurses’ specialty certifications. This study identified significant areas that are important to support nurses seeking certifications. Additional research is needed to evaluate which interventions significantly impact initial and continued certification levels, especially in the post-COVID-19 era.

What is known?

• •Research suggests direct relationships between nursing specialty certifications and patient care quality.
• •Expectations of certification have been strongly promoted in the nursing profession.
• •Even though the benefits are shown in research, and there is an incentive drive with the Magnet designation, nurses’ professional certification rates are still low.

What is new?

• •Organizations need to develop an organizational culture that promotes nurses’ specialty certifications.
• •Leadership plays a significant role in establishing and maintaining a positive organizational culture and a continuous learning environment.
• •The strategies to promote nurse specialty certifications include sharing resources, facilitating a culture of ownership and a sense of belonging, mentoring and role modeling, recognizing nurses’ efforts and accomplishments, and cultivating a sense of meaning, purpose, and support.

1. Introduction

Nursing specialty certification validates nurses’ proficiency in specialty knowledge related to clinical nursing practice, education, or leadership beyond entry-level education and licensing. Nurses can become certified in their practice-based specialty by studying for and passing an exam that demonstrates proficiency in the knowledge, skills, and attitudes required to provide high-quality care to patients and their families [[1], [2], [3]]. Certification fosters nurses’ professionalism, commitment, and responsibility for continued professional development, learning, and high-quality patient care [4,5]. By obtaining a specialty certification, nurses demonstrate expertise in areas such as perioperative, critical care, pediatrics, or oncology.

Literature indicates that achieving a specialty certification enhances nurses’ knowledge and skills in a specific practice area and shows nurses’ commitment to providing the best possible care to their patients. Research suggests direct relationships between nursing specialty certifications and patient care quality, including patient mortality rates [6], fall rates [[7], [8], [9], [10]], hospital-acquired infection rates [2,11,12], and better hospital work environments [13]. Boyle and colleagues [11] found inverse relationships between the central-line–associated bloodstream infection in surgical intensive care units and the rates of certified post-anesthesia nurses, operating room nurses, and registered nurses’ first assistants in perioperative units. Thus, expectations of certification have been strongly promoted in the nursing profession.

The value of certification has been supported by American Nurses Credentialing Center (ANCC) Magnet® Designation program. To apply for or maintain Magnet® designation, organizations need to develop plans to increase nurse certification rates [14,15]. Boyle et al. [15], using a seven-year trend analysis of data from the National Database for Nursing Quality Indicators, noted that Magnet® designated hospitals reported to have better structural supports had increased certification rates over time than non-Magnet® hospitals. Nurses’ specialty certification rates are one of the standard principles of the Magnet® designated hospitals, showing the value of nurse certifications. Hospital leaders, especially leaders in Magnet® Hospitals and those in the process of applying, strive to promote nurses’ specialty certification rates, a proxy and benchmark for nursing care excellence and quality patient care [14,15].

Even though the benefits of certification have been supported by research, nurses’ specialty certification rates are still low in the 30th percentile [13]. There is a gap in the literature about nurses’ perceptions of the facilitators and barriers to becoming certified, especially in the post-COVID-19 pandemic era. Identifying factors influencing nurses' decision-making process in becoming certified will be valuable knowledge for organizations, nurses, educators, leaders, and researchers to design and implement future education and intervention programs. This study aims to better understand nurses’ perceptions of the facilitators and barriers in promoting nurses’ desires and ability to obtain specialty certifications, which exclude advanced nursing practice roles, such as nurse practitioner or nurse midwife.

2. Methods

2.1. Study design

This is a qualitative descriptive study. Qualitative description is brought forth by a renowned qualitative researcher, Margarete Sandelowski. Sandelowski [16] pointed out that among the immense qualitative methods literature, it lacks the “comprehensive description of qualitative description as a distinctive method of equal standing with other qualitative methods, although it is one of the most frequently employed methodological approaches in the practice disciplines.” Qualitative description is a method suitable to healthcare research as it delivers genuine responses concerning people’s experiences about a particular event or situation and perceptions of pursuing or not pursuing certain events – circumstances or factors affecting their decisions or actions. This study aims to better understand nurses’ perceptions of the facilitators and barriers in promoting their desires and ability to obtain specialty certifications, which made the qualitative description the study design of choice.

2.2. Ethical consideration

This study was approved by the University of Louisville Institutional Review Board (IRB number 21.0844).

2.3. Setting and sample

This study took place virtually and included nurses from across the United States from May 2022 to September 2022. The study sample was a nested sample of a large national survey study. At the end of the national survey study, the participants were asked whether they would like to be contacted for a follow-up interview. Among the nurses agreeing to be interviewed, a purposive sampling method was used to achieve maximum variation in diversity, such as years as a nurse, race, ethnicity, and certification status. We recruited participants who were both certified and non-certified to explore facilitators and barriers. Information saturation was applied to gauge sample size [17]. The initial online survey aimed to recruit registered nurses without limitations of specialty certifications. The inclusion criteria for the participants were registered nurses, certified or non-certified, willing to share their experiences and perceptions of the facilitators and barriers to pursuing nurse specialty certifications. Nurses were excluded if they were not willing to share their experiences.

2.4. Data collection

Two forms of information were collected from the participating nurses: a demographic form and an in-depth virtual face-to-face interview. The demographic form included information such as age, ethnicity, education, and years of working experience. The first author conducted in-depth interviews using minimally structured open-ended questions to investigate nurses’ experiences with specialty certification. The grand tour question was, “Could you please describe your role as a nurse on this unit?” Other questions included, “Could you please tell me what makes you want to be certified?”, “Can you tell me the importance of you to become certified?”, “Can you tell me nurse leaders’ roles in facilitating nurses to become certified?”, “What can organizations do to support nurses’ decisions to become and maintain certification?”, “What are the influences that nurse peers have on nurses’ decision-making to be certified?”, “How can nurses be role models for one another, especially newly graduated nurses?”, “What helps you become certified?” and “What can help nurses who are not certified change their minds to seek certification?”. If nurses interviewed were not certified, the reasons were explored. Probing questions included, “What was that like?”, “How did that feel?” and “What were you focusing on at that time?” to help clarify and understand nurses’ thoughts and feelings.

2.5. Data analysis

The process of the data analysis was a team effort. First, two authors conducted the first-round coding independently, cross-checked, and established the major themes, the validity of which was double-checked and verified by two other authors independently. The coding process was based on Colaizzi’s [18] data analysis methods. We applied this rigorous qualitative method to find, understand, and describe nurses’ experiences of becoming or not becoming certified. Two authors were the primary coders of the data. The analysis process included a) reading the transcripts thoroughly; b) looking for patterns of nurses’ experiences with certification; c) writing memos while reflecting on the patterns; d) extracting statements about everyday experiences; e) categorizing the statements into themes; f) transforming participants’ descriptions into a written report; g) validating the findings via member checks; h) integrating member’s feedback into the final written report [18]. Furthermore, member checks were performed after the interviews. Two informants were invited to read the themes and the supportive narrative examples, who confirmed the themes and narratives.

3. Results

3.1. Demographics of the participating nurses

Twenty nurses participated in the study. Data saturation was reached at participant number 17, after which three more interviews were conducted to ensure data saturation. Table 1 shows the participants’ demographic, including race, gender, degree, age, years as a registered nurse, Job satisfaction in the last three months, and plan to leave within a year.

Table 1.

Demographics of the participating nurses.

Variable		Certification
		Yes	No
Gender	Female	10	7
	Male	1	1
Degree	Baccalaureate	5	4
	Master	4	0
	Doctorate	2	5
Race	White	9	5
	Black	2	2
	Native Hawaiian	0	1
	Two or more mixed races	0	1
Job satisfaction in the last three months	Very high	3	2
	Moderate	7	6
	Little/Not at all	1	1
Plan to leave within a year	Likely/Very high/Very Likely	1	3
	No	10	6
Age		42(27–72)	51(24–68)
Years as an RN		15(6-50)	20(1-46)

Note: Data are n or Median (range).

3.2. Organizational culture and roles to promote nurses’ specialty certification

The informants provided insights into the factors influencing nurses’ desires and ability to pursue specialty certifications. Based on the informants’ perceptions, organizations play a significant role in promoting nurses to pursue specialty certifications. The facilitators and barriers were categorized into five major themes: 1) sharing resources, 2) a culture of ownership and a sense of belonging, 3) mentorship and role modeling, 4) recognizing nurses’ efforts and accomplishments, and 5) cultivating a sense of meaning, purpose, and support. The major themes are described below, and Table 2 displays the themes and supportive quotes.

Table 2.

The overall nurse certification evidence matrix.

Themes	Meaning	Selected supportive narrative examples
Sharing resources	Resources refer to healthcare professionals with specialized knowledge, certification study guides, and co-worker study groups.	• “We can all be resources to each other. When we share resources, we can help one another and can all be [certified].” • “What I would tell them is the benefits of being certified … [Through the certification processes, events, and activities], we can create relationships, build friendships, talk to others, and say, hey, how did this work for you? How did it work for your unit or organization? So that we can bring the information back to our unit. If it worked there, then we can make it work.” • “Collaboration is a way to share knowledge as a resource.” • “As a team, we share resources. If nurses want to be certified, we [the leaders] provide them with resources, such as books, materials, and study groups. The other thing is [that] we encourage it [getting certified]. For those that get certified, we praise them and recognize them. We also advocate that, hey, [a nurse’s name] is a certified nurse now. They are a resource and can be your go-to person.” • “Our unit has a folder with resources to share if someone wants to be certified. We have the review materials saved on a G drive, like our common drive, a certification folder with all the resources nurses need to study for the exam.” • “As a nurse leader [on my unit], I believe sharing is caring and always try to create a welcoming environment for all nurses, including those who were pulled to work here.” • “As a nursing development director [in my organization], I collaborate with other hospital directors, and we share resources [at the organizational level]. If one of us finds an online session for a certain certification, we always share and communicate with our staff about upcoming study events they can attend. We also let them [nursing staff] know about the organizational offerings.”
A culture of ownership and a sense of belonging	Encouraging nurses to obtain their certification can help nurses develop an ownership mentality and a sense of belonging.	• “[As a certified nurse], I receive emails [from the certification organization] and am informed about events. I join some events and feel connected.” • “I would say peer support makes me feel a sense of belonging. So, I want to do things to help others have the same feeling too.” • “I am not certified yet, but I want to [become certified]. I want to be like my colleagues [who are certified] to belong to a professional group.” • “I want to be involved [in organizational groups]. One example is shared governance, and if I become a subject matter expert there, I can help plan the educational curriculum and teach. But, if I am not certified in that area, I cannot be part of that.” • “The organizational culture plays a big role [in promoting nurse specialty certification]. I don’t want to be the only one in the group without my [certification] badge.” • “It’s kind of going back to the [organizational] support, which can encourage me to look at my professional growth and evaluate where I am and where I want to go. Achieving certification is a good way to get to where I want.”
Mentorship and role modeling	Mentorship and role modeling are fundamental in guiding and supporting others to achieve nurse specialty certification.	• “What makes me want to be certified is to be considered a mentor in my specialty. I like to go to colleagues who are certified for advice, and I want to be a mentor for others. If others see that I am certified and engaged [at work], then that’s the opportunity for others to reach out to me for advice or help.” • “Role modeling is powerful. It’s like if others can do it, I can do it; If I do it, then others may follow too.” • “When we [nurses certified] are engaged at work, those that are not certified may reach out to us for help. One time, I had someone who came to me for advice. I shared my study materials and my experience. I also shared what the organization pays and supports, which they may not know. Sometimes, I reach out to the nurses who are not certified and ask whether they want to study together. It’s kind of walk the talk.” • “A nurse leader is a role model, a mentor, a guide, and a support person. As a leader, I need to be certified. If I encourage others to pursue certification, I’ve got to do it first. I’ve got to talk the talk and also walk the walk.” • “It is imperative for nurse leaders to have their certifications. It’s hard to be a motivator or tell somebody to get certified if they are not themselves, and there's no way around it.” • “As a unit manager, I try to get new nurses to look towards certification and to show them that, since they love this specialty, they may consider getting the certification.” • “I think my instructor in the perioperative course influenced me. She said you’ve got to get your certification. She was very nice and kind, and I wanted to be like her.”
Recognizing nurses’ efforts and accomplishments	Recognition is essential in motivating and inspiring nurses to obtain specialty certifications.	• “My organization makes it a big to-do about certified nurses. The organizational leaders understand the importance of being certified and recognize the hard work that nurses put in to be certified. They celebrate with certified nurses and set up a culture of recognition. When the nurses not certified see the celebration and the value of being certified, they want to do it too.” • “When someone’s certified, everyone on the unit will know. The nurses get certified and will have a name badge showing they are certified. The unit will celebrate with balloons and hang a plaque with their names on the wall. The nurses’ names will also appear in the organization’s Facebook group and the health system’s weekly newsletter. So, it’s a big thing to do because they want to honor and praise the nurses for their hard work to be certified.” • “My unit has a certified nurses’ wall, where all the certified nurses have a picture and a plaque. People want to be recognized and are motivated to be certified.” • “I work in a small community hospital, and the hospital didn’t promote it. Maybe it’s too inexpensive to do, and I don’t know. It would be nice if the organization could promote it and gain recognition.” • “I felt good [to be certified]. I am proud to wear that pin and badge to show everybody and tell them that I got my certification. So, I felt good, and I got to put another credential after my name, yeah.” • “The recognition makes me feel proud, empowered, and more confident. I feel empowered and self-confident to do more.” • “My organization has a professional development ladder. People can earn points by doing certain things to be promoted to a higher rank.” • “In some hospitals, individuals with certifications ranked higher, an incentive to achieve more. Some organizations reward their staff for doing above and beyond. My hospital does not do that, which may be something to look for in the future.”
Cultivating a sense of meaning, purpose, and support	Organizations can promote nurses’ inspiration for specialty certification by cultivating and co-creating purpose and meaning with their nurses. The incentives could be the necessity for professional growth, clinical ladder, clinical expertise, or financial support and incentives, such as paying for the exam, renewing certificates, and wage increases.	• “My organization pays for nurses to take review courses and certification exams to encourage nurses to be certified.” • “I think that extra incentive pay helps motivate many nurses. Like when I worked at one facility, they gave me an extra paycheck to be certified, which was nice. My current job doesn’t do anything, so I’m the only certified nurse there and can’t talk others into getting certified because they don’t see any incentives. So, I think that incentives, which can be little, might help.” • “However, not all organizations provide incentives, which differ from organization to organization.” • “For me, at this stage of my nursing career, if it does not benefit me, knowledge-wise or financially, then I don’t want to do it because there’s no value in it because it’s not worth the time to do it for me.” • “Some hospitals will do reimbursement if you pass, but you have to pay for it upfront and then take it. So, you know it’s a few hundred dollars to take the certification exam. With everyone’s personal family/life situations, some may not afford the $400 to take their certification.” • “So, without a meaningful purpose, nurses may say, well, why would I want to be certified? To be certified, I have to spend extra time studying, a few hundred dollars to get my certification, and more money to obtain extra continued education credits and renew it every few years. I can see how some people would not think that that is worth it.” • “Our organization offers vouchers for certain certifications. They have partnered with different certifying bodies and paid for everything, and the staff doesn’t have to pay anything out of pocket and just go to take that certification exam. So, removing that financial barrier is an organizational strategy.” • “Having the support of your direct leader is even more vital than having the support of, like, the whole organization because having that encouragement and recognition from your direct leader, you know, that’s the fact that nurses see every day when they come to the unit.”

3.2.1. Sharing resources

Completing a professional nursing certification is no easy feat and requires many hours of studying and the necessary study material. These materials can be expensive. Finding time and motivation to learn and study can be difficult due to nurses’ busy schedules and routines, compounded by the severe nursing shortage across the nation. Organizations can address these issues by creating a shared resource pool. This includes study materials and organizing study groups/review sessions for nurses pursuing the same certification.

Almost all the participants noted the importance of organizing group study sessions. It is important to share resources and “build that camaraderie with a group dedicated to testing simultaneously.” A nurse educator spoke about their efforts to “eliminate a [financial] barrier” for nurses by “putting together a study group or study review course.” Sharing resources is cost-effective and allows nurses to support one another. As one nurse mentioned, “it’s much easier to study with other people than by yourself.” However, study groups and resource sharing will only be influential if nurses are aware of the available resources. The interviewees pointed out the necessity of nurse leaders ensuring that the study resources available for certification are made known to the staff.

One nurse expressed that she was unaware of the resources available as a new nurse and missed out on helpful information. To prevent this issue, organizations need to create a shared resource library that is widely shared by nurse leadership and promoted by nurses who are already certified. One charge nurse described their resource library, where they have collected books from nurses who have already gained their certification. This library gives nurses free access to study materials such as practice questions. In most units, the chances are high that at least one nurse is already certified and therefore has study materials and information about the certification process. As one nurse director said, “why reinvent the wheel? Somebody has a wheel, and let’s make the wheel fit your automobile.” Sharing resources is a cost-effective way for organizations to promote professional nursing certifications, through which organizational leaders show their support to encourage nurse certification. Almost all participants said that having the support of direct supervisors or leaders was vital because the immediate nurse leaders were the persons whom they encountered every day at work. Nurse leaders’ encouragement and support are essential in supporting nurses to pursue their specialty certification.

3.2.2. A culture of ownership and a sense of belonging

Encouraging nurses to obtain their certification can help the organization to facilitate a culture of ownership and help nurses develop a sense of belonging. More than half of the nurses interviewed expressed that fear of failure was a barrier to getting a specialty certification. Organizations can promote specialty certification by emphasizing its importance and assuring nurses they can succeed.

When asked what specialty certification meant to them, one nurse said, “Personally, I think a sense of self-pride, that I’m a content expert in my field. I’m a lifelong learner, so [I was motivated to pursue] that professional development and continuation.” Many nurses echoed similar versions of this response and noted that they felt empowered and more confident due to their certifications. One unit director spoke about motivating nurses on their unit by encouraging them, “pursuing certification shows great accomplishments, which makes you feel achieved and empowered. The specialty certification demonstrates your commitment and knowledge and shows patients that you are an expert in this area.” This director showcases how nurse leaders can foster a culture of ownership and a sense of belonging in their units. Organizations can promote certification by making it a priority for nurse leaders to motivate staff nurses to take ownership of their professional development and reassure them that they are more than capable of passing the test. A participant pointed out, “I do think there is an element of being self-motivated that is hard to create.” While nurses decide for themselves that they want to pursue certification, nurse leaders can be encouraging and reassuring every step of the way. Certification demonstrates the knowledge many nurses already have. One participant noted, “you do it every day taking care of your patients, and you have the knowledge. It’s just a test you have to take.”

Another way organizations can foster a culture of ownership and a sense of belonging is to get nurses involved in unit improvements. One nursing program director described how they conducted a strategic management technique called a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis to identify their unit’s strengths, weaknesses, opportunities, and threats. They left posters in the break room with each category, and nurses filled them in for six weeks. After analyzing the responses, one of the three main priorities for the unit was increasing certifications. By allowing nurses to have a say in the unit improvements, this program director created unity and “a shared purpose, for [leadership] and for the team.” When creating this unity, this belonging becomes an organizational priority. Nurses recognized the value and benefit of specialty certification for patients, their unit, and organization, “the more you continue to learn and progress and share that knowledge, the better you and your co-workers will be.” Nurses will be more motivated to pursue their certification because they are doing it not only for themselves but for the good of the team and the patients.

3.2.3. Mentorship and role modeling

Mentorship and role modeling are vital in promoting specialty certification. By acting as mentors and role models, nurse leaders and experienced nurses can inspire other nurses to continue their professional development and education. Organizations can promote specialty certification via role modeling, annual evaluations, and nurse leadership expectations.

Some interviewed nurses said they were motivated to become certified because of a mentor. As less experienced nurses, they looked up to those with certifications because they understood the competence and knowledge it demonstrated. When a mentor reached out to them, they understood the importance and wanted to expand their knowledge base. Specifically, one nurse described a nurse they looked up to during the beginning of their career, “she was a great OR nurse,” who encouraged the participant to pursue certification so the participant could take over the older nurse’s position once she retired. The participant said they wanted to be like that nurse and so their mentorship regarding certification was taken very seriously.

To promote certification, organizations need to create mentorship programs that emphasize professional development in a similar way. For example, pairing certified and non-certified nurses together encourage them to share resources, share their experiences with the test, and offer encouragement. One nurse spoke of her experience mentoring and encouraging other nurses to pursue their certification, “a lot of times, I’ve approached nurses and said, ‘hey, I noticed that you take really good care of our patients and that you’re very dedicated. I think [certification] would take you to the next level … and I can help you get there.’” Multiple nurses in this study mentioned that they had encouraged other nurses on their unit to become certified and reassured them that the test wasn’t as difficult to pass as they might think. They modeled to others that it is possible, “if she can do it, then I can do it.”

Nurses in this study also spoke about the effectiveness of including certification promotion in annual evaluations with nurse managers. During these evaluations, the nurse makes goals for the year with their nurse leader. If made an organizational priority, this is the perfect opportunity for nurse leaders to encourage and set goals for certification. However, for this method to be most effective, nurse leaders need to model the behavior they are trying to promote. One nurse said it’s “important for nurse leaders to have their certifications already. It’s hard to be a motivator … who says, ‘hey, you should get this if you’re not somebody who already has it themselves.” To show a true commitment to certification promotion, nurse leaders may demonstrate a personal commitment and enthusiasm for professional development. As a nurse leader, you should “talk the talk and walk the walk too.”

Organizational policies to promote mentoring and role modeling would make the certification a requirement to hold nurse leadership positions and make it an organizational priority. By making the certification a requirement to be a charge nurse, for example, “if the new graduate wants to promote themselves on the unit … they would have to obtain that certification.” This way, when nurse leaders encourage certification on the unit and in annual evaluations, they can speak to their personal experience and explain precisely what it takes to become certified and the benefits it provides. Additionally, organizations need to demonstrate that increasing certifications is a priority. One nurse said her Chief Nursing Officer uses her quarterly nursing forums to highlight important statistics to the hospital. This CNO mentions BSN and certification rates to keep the staff updated on their progress and encourage professional development.

3.2.4. Recognizing nurses’ efforts and accomplishments

Obtaining a nursing certification is a difficult task and should be celebrated. Nurses deserve recognition for their devotion to themselves, their patients, and the field. And not only do the nurses deserve this recognition, but public praise will also inspire others to become certified so they can be recognized. The organization can promote professional nursing certification by distinguishing certified nurses from non-certified nurses, using plaques to honor the achievement of certification somewhere on the unit, and rewarding nurses who pass their tests with small gifts.

Certified nurses can be distinguished from their peers through position levels and name badges. One nurse mentioned having level 1 and level 2 nurses, not to insinuate certified nurses are inherently better, “but just an extra layer of recognition for [certification].” Additionally, multiple nurses touched on changing name badges to reflect your certification status as an effective and low-cost organizational policy that promotes certification. A nurse said, “I’m proud to have that certification because I have the initials on my badge. And parents all the time ask, ‘what do those initials mean?’” This nurse said they were excited to convey the meaning of their certification because it demonstrated to the parents that the nurse caring for their sick child has a specialized background. Similarly, another nurse said their certified nurse badge “instilled confidence in the patients. When they see that, they know this nurse is certified, so they’ve got to be a good nurse.”

Another way the organization can promote certification through recognition is to put plaques on their units that list all certified nurses by name. The nurses in this study said it was essential to recognize certified nurses in this way because it allows patients, patient families, and other staff to know who is certified. It demonstrates the unit’s competence and honors the nurses who obtained certification. Multiple nurses noted that they appreciated a unit plaque recognizing their accomplishments because “they felt like it represented our teamwork and their work and their contributions to the team.”

Nurses’ efforts and achievements can also be recognized through rewards such as small gifts or celebrations. For example, some nurses talked about giving out balloons, flowers, and candy or having luncheons to celebrate nurses who achieved their certification. A nurse working as a stroke coordinator said, “little things like that can mean a lot to nurses, especially in the environment of being short-staffed in the post-COVID world we live in.” Not only does this validate the efforts of nurses who are already certified, but it also encourages other nurses to pursue their own professional development, “other people think, oh, we think we’ll want to get certified, we want [that] recognition too.”

3.2.5. Cultivating a sense of meaning, purpose, and support

Taking certification exams and renewing certifications can cost hundreds of dollars, which creates a significant financial burden for those who may already struggle to make ends meet or those who do not see a value or need to obtain certifications. The nurses without a clear meaning and purpose of becoming certified expressed reluctance to pursue specialty certifications. Organizations can promote nurses’ inspiration for specialty certification by cultivating and co-creating purpose and meaning with their nurses. The incentives could be the necessity for professional growth, clinical ladder, clinical expertise, or financial support and incentives, such as paying for the exam, renewing certificates, and wage increases. The major difference between the nurses who were certified and those who did not want to was the purpose and meaning of obtaining specialty certifications.

While almost all the nurses interviewed talked about the cost of preparation, the initial exam, and the renewal, the reflections on the cost were different. The cost was not a barrier for those who valued specialty certifications and wanted to become certified. One nurse expressed, “I am not certified yet but plan to. In my hospital, I need to become certified before I can be promoted. I want to go up the clinical ladder, which motivates me to be certified.” Another nurse said, “I like to join my specialty organization, attend its conferences, and meet colleagues from the same specialty area, which makes me feel informed and connected.”

However, if nurses do not see the value of specialty certification, they see the preparation effort and the extra spending as significant barriers. In this study, while other nurses might discuss the cost and effort to study, one nurse clearly expressed that she did not feel it necessary to become certified. This nurse said, “for me, at this stage of my nursing career, if it does not benefit me, knowledge-wise or financially, then I don’t want to do it because there’s no value in it because it’s not worth the time to do it for me.” Suppose nurses do not see the value of being certified. In that case, they are not inclined to spend money on the initial test and renewing their certificates when they are not receiving any sort of financial incentives or support from their organization. One nurse who has not yet been certified said, “I am interested in the knowledge part of it, but the incentive at our hospital … just doesn’t seem to be great enough to do it.” A nurse educator noted, “there’s also experienced nurses who’ve been here 40 plus years, who have just as much skill and knowledge as the certified nurses who aren’t going to become certified because of [a lack of financial incentives].” By offering to cover the cost of certification exams, organizations are demonstrating their commitment to their staff’s professional development and relieving their nurses’ financial burden. Nurses will know that “if I study, if I work hard, and I get [my certification], it’s not going to cost me anything, and it’s going to help me in my future.”

Along with paying for the test and certification renewal requirements, organizations can offer wage increases for certified nurses. If an organization truly values certification, it will demonstrate that to its staff by compensating them monetarily. One nurse said, “[at my organization] if you have certain certifications, you get a slight pay increase … [certification] seemed heavily respected, and [the organization] wanted to compensate you … for having that extra knowledge and being a resource … because once you have that knowledge and practice, you are a resource to other nurses and the hospital.” This quote highlights the importance of recognizing nurses’ efforts through their wages because their professional development is also a development of the hospital’s competence and credibility. Organizations need to find ways to co-create meaning with their nurses and cultivate a sense of purpose and support.

Another aspect was the influence of the COVID-19 pandemic on nurses’ perceptions of specialty certifications. Most (80%) of the nurse participants voiced no apparent negative effect. One nurse said, “some nurses liked the accommodations of the credentialing and testing centers during the pandemic.” Yet, 20% of the participants mentioned that the pandemic had negatively affected their thoughts about certification and that taking specialty certifications was no longer a priority for some nurses. Nurses expressed that organizational support played a significant role in nurses’ sense making about the certifications, especially during difficult times like the COVID-19 pandemic.

4. Discussion

This study explored nurses’ perceptions of the facilitators and barriers in promoting nurses’ desires and ability to obtain specialty certifications. The informants provided insights into the factors influencing nurses’ desires and ability to pursue specialty certifications. Based on the informants’ perceptions, organizations play a significant role in promoting nurses to pursue specialty certifications. The facilitators and barriers were categorized into five major themes: sharing resources, facilitating a culture of ownership and a sense of belonging, mentorship and role modeling, recognizing nurses’ efforts and accomplishments, and financial incentives and support.

These major thematic findings indicate that the factors and effects of nurses’ decision to pursue or not to pursue specialty certifications are not linear but rather multilayered and intertwined. The findings have highlighted some leadership capabilities and opportunities at the organizational and/or level levels to facilitate and support nurses’ specialty certification. The facilitators and barriers are two sides of a coin, and organizational leaders play a significant role in turning barriers into facilitators. For example, one barrier preventing nurses from pursuing specialty certification is the cost of materials and examination and the time to study. Participants suggested that sharing resources and developing study groups were great facilitators and could contribute to ongoing peer support as nurses strived to achieve certification. To increase nurses’ awareness of existing resources, organizations could choose various approaches to sharing resources, such as increasing awareness of existing resources, providing education opportunities, and encouraging group and peer support [19]. Research shows that nurses who received reimbursement from their organizations perceived significantly higher extrinsic values than those who did not [20]. Unit leaders may create a resource-sharing site where nurses can share their review materials, such as books, practice exams, courses, and tutorials. Sharing also delivers a message of caring, creating a positive and uplifting learning environment. Thus, sharing resources can reduce individual costs and lessen the burden in preparation for the certification exam, which may turn into a barrier to a facilitator.

This study was consistent with the current literature on the importance of the unit-level immediate supervisor or leadership support. The participants in this study expressed that the support they experienced from the direct supervisors or leaders at the unit level was vital because these leaders were the immediate supervisors and support whom nurses encountered every day. Research on healthy work environments suggests that unit leaders play a significant role in nurses’ job performance and professional development. Unit leaders are often the middleman who mediate and moderate between organizational policy and unit-level implementations. They play a significant role in building and maintaining relationships between employees and organizations and promoting positive organizational cultures. Thus, unit leaders’ encouragement and support are vital to encourage nurses to pursue a certification.

Facilitating a culture of ownership and a sense of belonging is supported by providing initial and ongoing recognition of nurses who achieve certification. Participants expressed that validating and gaining additional knowledge through preparation and completion of the exam supports personal pride, facilitating a culture of ownership and a sense of belonging [[21], [22], [23]]. Mentorship and role modeling by leaders and experienced clinicians can set the tone and generate the expectation of certification as part of the professional role. Role modeling can be the nucleus for growing momentum as both formal and informal nurse leaders “walk the talk” of achieving certification and contribute to a culture that values certification [24,25]. Research shows that on-job mentorship programs can improve nurses’ experience and motivate them to promote patients care [23,26] and nurses’ professional development [22,27,28]. Certified participants in the study indicated they had a sense of responsibility for becoming a mentor and sharing resources with other nurses. The mentorship can be sharing resources, encouraging, and role modeling. This study finds that a mentor is someone who can reach out and work together with co-workers to bring them up to a higher level of nursing excellence. Being a role model is leading by example.

As indicated in the study, nurses felt proud to be certified, especially when organizations and nurse leaders recognized their efforts. McLaughlin and Fetzer [29] had similar findings regarding nurses’ perceived value of specialty certifications; informants identified intrinsic factors to pursue certificates, including pride in self and a sense of accomplishment as motivators to become certified. With organizational culture, structure, and processes that support certification, the research identified six extrinsic values, including employer, professional, and peer recognition, ranked second, third, and fourth respectively, with increased marketability ranking first in this study with both certified and non-certified nurses. These rankings show nurses place a high value on overall recognition of their achievements. Our study finds that some hospitals may not promote or recognize nurses’ efforts or certification. It may need further exploration about whether the hospital size has any relationship with nursing support to get certified and whether leadership without certification makes a difference.

The research identified three significant factors affecting their intrinsic value for pursuing their specialty certifications: recognition of specialization, a sense of personal achievement, and perceptions of professional accomplishment [30]. This study found that organizational culture, recognition, and financial support may help promote nurses to pursue certifications. The findings indicate that nurses are not motivated to do it if they do not see the value of getting certified. Organizations need to facilitate a culture that values nurses’ hard work and efforts to be certified, such as a professional ladder system, promoting nurses’ professional growth and financial incentives.

This study also recognized that organizational leadership played a significant role in creating and maintaining a continuing and collaborative learning culture, which, research shows, is associated with patient care quality, nurse performance, and organizational enactment [27,31,32]. In this study, 11 (55%) respondents have advanced degrees. We did not find significant differences in statistical analysis. However, based on the interviews, we found that those nurses who created the meaning and purpose of specialty certifications had a more positive attitude toward continued efforts of exam preparation and certification-incurred cost. The cost was a concern for some, but for those who created a meaning of obtaining their certifications. Thus, organizations need to cultivate a supportive culture in which organizations can help nurses develop the purpose of obtaining specialty certifications. The incentives may be leadership opportunities, clinical ladders, or financial support and incentives, which can only be done at the organizational level. Thus, it is important for organizations to co-create meaning with their employees, who support the organization and improve patient care quality. Statistically, there were no significant differences between certified and non-certified nurses in demographics. Specialty certification is more related to professional development, such as clinical ladder advancement, which can be obtained by any degree. Thus, we did not see significant differences among nurses with Baccalaureate versus graduate (Master’s or Doctorate) degrees. This phenomenon can be further explored.

The COVID-19 pandemic has devastated the world and placed a heavy toll on healthcare organizations and providers [[33], [34], [35]]. The participants in this study had split opinions regarding the influence of nurses’ perceived values in pursuing specialty certifications during the pandemic. While most (80%) of the nurse participants said that the influence was not evident and that nurses realized the importance of having specialty certifications, 20% mentioned that the pandemic had placed specialty certifications on a lesser priority list. Nurses liked the alternative accommodations the credentialing and testing centers offered during the COVID-19 pandemic. Organizations need to know nurses’ concerns, encourage nurses to voice their desires, and help nurses make meaning of their work. When creating the purpose of their specialty certification, nurses can recognize the value of their knowledge and expertise and its impact on their practice and the nursing profession.

5. Limitations

This qualitative study has several limitations. First is the limit in generalizability. Because of the qualitative study’s characteristics, the findings are not generalizable. Nonetheless, this study provided a better understanding of nurses’ perceptions of the facilitators and barriers in promoting nurses’ specialty certifications and explored organizational strategies to cultivate a culture of sharing, ownership, support, and a sense of belonging. Secondly, two groups of nurses, certified and non-certified, participated in the study. About half of the participants have a graduate degree, seven of whom have a doctoral degree. This study did not focus on the effects of education on nurses’ perceptions of certification, a valuable phenomenon to study.

Furthermore, during the data analysis, we noticed a phenomenon where certified nurses and those who planned to become certified had a more positive attitude toward the efforts and cost of getting certified. Some nurses cherish the intrinsic value of improved knowledge and pride, and others may look for the extrinsic value of recognition by others or financial incentives. A better understanding of these is needed and would help prioritize organizations’ efforts to increase certification rates.

6. Conclusion and recommendations

The study findings indicate that organizational culture and leadership significantly promote learning environments essential to the choice to seek certification. Nurse leaders’ role modeling, recognition, resource sharing, and financial support influenced nurses to make certification decisions. The development of an organizational culture that promotes nurses’ specialty certifications was identified as an underlying foundation built on recognizing the achievement of certification. Additional research is needed to evaluate which interventions can significantly impact initial and continued certification levels, especially in the post-COVID-19 pandemic era. The association of specialty certification with quality and operational outcomes continues to be an important area of research to enable nurse leaders to provide the structural support needed that fosters the desire for recognition of expertise in specialty areas of practice.

Funding

This study was supported by the CCI Research Foundation [CCI OGMB220365, 2022] and East Tennessee State University College of Nursing.

CRediT authorship contribution statement

Holly Wei: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Project administration. Lisa M. Haddad: Writing-reviewing & editing. Tricia A. Nwokocha: Writing-reviewing & editing. Margaret Powers: Data curation, Writing- original draft. Aaron Wei: Data curation, Writing- original draft. Quinton Carroll: Data curation, Writing- original draft. Nancy Ballard: Writing- original draft, Writing-reviewing & editing.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article.