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Developing the Continued Professional Certification Program for Nurse Anesthetists
Developing the Continued Professional Certification Program for Nurse Anesthetists Steve Wooden, DNP, CRNA, NSPM-C; Mary Anne Krogh, PhD, CRNA; Ed Waters, CRNA, DNP; and Karen Plaus, PhD, CRNA, FAAN, CAE Recertification assures the public that a certificant remains competent throughout his or her career and has knowledge and skills beyond those needed at entry into the profession. Health professions address the concept of recertification using many different approaches. In 2008, the National Board of Certification and Recertification for Nurse Anesthetists, or NBCRNA, initiated a recertification redesign, and, in 2016, it launched the continued professional certification program. The initiative included a benchmarking study of the recertification programs of other health and medical professionals and an analysis of the literature to identify credentialing best practices and trends. Surveys and other communications in coordination with the American Association of Nurse Anesthetists solicited input of nurse anesthetists. This article reviews the key findings, trends, and influences for the continued professional certification program and the process the NBCRNA used to create and implement a recertification redesign to support lifelong learning and the expanding role of nurse anesthetists.
Keywords: Continued competence, nurse anesthetists, professional development, recertification
I
n 1969, the American Association of Nurse Anesthetists (AANA) adopted continuing education (CE) as a voluntary component for recertification. In 1978, it became a requirement. The recertification program required nurse anesthetists to complete a minimum of 40 hours of CE, attest to a minimum number of practice hours, and maintain nursing licensure. The recertification program remained in place without substantial modifications until 2016 (AANA, n.d.). A compelling argument for changing a program of 40 years must answer critical questions: ⦁ What has changed in and around the profession to warrant changing the recertification process for nurse anesthetists? ⦁ Will changes to the recertification process add value to a nurse anesthetist’s credential? To answer these questions, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) undertook a 3-year research initiative to identify best practices and trends in health professions education and a 4-year period of review and modification.
Influences Literature
The Institute of Medicine’s (IOM’s) 2001 report, Crossing the Quality Chasm, found that despite the rapid advance in medicine and technology, the health care system “frequently falls short in its ability Volume 8/Issue 1 April 2017
to translate knowledge into practice and to apply new technology safely and appropriately” (Institute of Medicine, 2001, 2, 3). The report recommended that CE emphasize a variety of approaches and a focus on evidence-based practice. As the report noted, “responsibility for assessing competence is dispersed among multiple authorities,” such as licensing boards, employers, professional societies, and accreditation groups, but “no consistent methods for ensuring continued competence of health professionals” exists (Institute of Medicine, 2001, p. 217). The IOM published a follow-up report in 2003, Health Professions Education: A Bridge to Quality, which called on health care profession boards to require periodic demonstrations of competence through assessment (Institute of Medicine, 2003, p. 13). The 2009 IOM study, Redesigning Continuing Education in the Health Professions, cited “major flaws in the way [CE] is conducted, financed, regulated, and evaluated” (Institute of Medicine, 2009, p. 6). The IOM report suggested that a vision of professional development was needed to focus the process on lifelong learning, including assessment and measurement of continued competence (Institute of Medicine, 2009, p. 38). In 2011, the Robert Wood Johnson Foundation and the IOM published the results of a 2-year study of the nursing profession. The report, The Future of Nursing: Leading Change, Advancing Health (Committee on the Robert Wood Johnson Foundation Initiative, 2011), identified the need for nurses to establish, maintain, and expand new competencies during their education and www.journalofnursingregulation.com
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TABLE 1
Professions Surveyed for Benchmarking Advanced Practice Nurses Nurse anesthetists Certified nurse midwives Nurse practitioners Independent Health Care Providers Anesthesiologists Medical examiners Optometrists Pharmacists Podiatrists Other Dependent Health Care Providers Anesthesiologist assistants Occupational therapists Physical therapists Physician assistants
throughout their career. The report recommended “accrediting, licensing, and certifying organizations’ need to mandate demonstrated mastery of core skills and competencies to complement the completion of degree programs and written board examinations” (Committee on the Robert Wood Johnson Foundation Initiative, 2011, p. 163). In 2005, the National Council of State Boards of Nursing (NCSBN) published a concept paper that identified the need for ongoing maintenance of continued competence (n.d.). In 2007, the American Board of Nursing Specialties Accreditation Council, now known as the Accreditation Board for Specialty Nursing Certification, implemented a requirement that recertification programs must have certificants demonstrate maintenance of knowledge over time and provide documentation showing how competence in the specialty is maintained over time. A more extensive review of the literature supporting the continued professional certification (CPC) program can be found in the document, NBCRNA Continued Professional Certification (CPC) Program: Evolution and Development, 2008-2014 (NBCRNA, 2014). Growth in Knowledge, Technology, and Skills
Health care knowledge is expanding rapidly. Densen (2011) estimated the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020, it is projected to be just 73 days. Nurse anesthetists who entered practice when recertification became a requirement have seen extraordinary changes in equipment, technology, and pharmacology. The first nurse anesthetists earned a certificate after completing a mentoring program in a hospital-based course of study. This approach evolved into a diploma program and, eventually, entry-into-practice education required a bachelor’s degree. By the 1990s, the educational requirement for entry level nurse anesthetists was a master’s degree. By 2016, approximately one-third of nurse anesthesia programs provide a doctoral degree for entry into practice, and all programs are required to be in a doctoral frame32
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work by 2022 (AANA, n.d.). Nurse anesthetists entering the profession today are educated to work in an increasingly complex and interdisciplinary practice environment. Although the education requirements for entry into practice have kept pace with changing healthcare needs, the recertification process for nurse anesthetists has not. Stakeholder Input
NBCRNA stakeholder groups include the public, patients, patients’ families, anesthesiologists, other physicians, hospital representatives, other employers, representatives of regulatory bodies, CE program providers, NBCRNA certificants, and representatives of the AANA. The stakeholders were included in the research initiative through literature reviews, surveys, and direct input at various stages in the process. In 2004, the Citizen Advocacy Center published Maintaining and Improving Health Profession Competence: The Citizen Advocacy Center Road Map to Continuing Competency Assurance, which argued that assurances of continuing competence of health care practitioners is an essential element of any program to improve patient safety and health care quality (Citizen Advocacy Center, 2004, p. i). This group called for reform of CE programs to ensure the continued competence of health professionals and periodic continuing competency assessment. In 2007, the American Association of Retired Persons (AARP) conducted a public opinion poll that sought to identify the perceived value of CE and assessment. The AARP reported that 80% of respondents indicated the importance of clinicians passing periodic examinations. Further, 95% indicated that doctors, nurses, and other health care professionals should be required to periodically demonstrate continued competence (AARP 2007). In 2011, Harris Interactive conducted a poll on behalf of the NBCRNA and the Citizen Advocacy Center to gain a better understanding of the public’s perspective on the credentialing standards required of their health care providers. The responses indicated that the public prefers that providers participate in a multimodal recertification program that includes periodic assessment of knowledge and lifelong evidence-based learning (NBCRNA, 2013).
Research: 2008 to 2011 In 2008, the NBCRNA conducted a professional practice analysis (PPA), targeting all NBCRNA-certified registered nurse anesthetists (CRNAs) eligible for recertification. The PPA focused on the practice of nurse anesthesia at a level more advanced than expected for initial certification. The core knowledge required of nurse anesthetists regardless of practice setting, patient profile, and work conditions was identified. The PPA was developed through a multistep process, including input from an appointed committee charged with analysis of the results. This process indicated that four core domains
TABLE 2
Benchmarking Recertification Requirements Among Medical Professions in 2008 Recertification components Nurse anesthetists
Frequency (y)
Current licensure
2
Yes
Continuing education (h) Periodic assessment
Practice
40
NA
850 hours
Anesthesiologist assistantsa
2
NA
40
Yes; 6 years
Not required
Anesthesiologists (MDs)b
10
Yes
350
Yes
Yes
midwivesc
5
Yes
20 (3 modules)
Proposed
Not required
5
Yes
25
Optional
1,000 hours
3
Yes
15–50
Yes
Not required
Certified nurse
Nurse practitioners (AANP)d Nurse practitioners
(NCC)e
Note. AANP = American Academy of Nurse Practitioners; MD = allopathic physician; NA = not applicable; NCC = National Certification Corporation. aSource: American Academy of Anesthesiologist Assistants. (n.d.). Frequently asked questions. Retrieved from http://www.anesthetist.org/faqs#recertify bSource: American Board of Anesthesiology. (n.d.). About MOCHA 2.0. Retrieved from http://www.theaba.org/MOCA/About-MOCA-2-0 cSource: American Midwifery Certification Board. (n.d.). Certificate maintenance program. Retrieved from http://www.amcbmidwife.org/certificate-maintenance-
program dSource: American Academy of Nurse Practitioners. (n.d.) American Academy of Nurse Practitioners Certification Board. Retrieved from http://www.aanpcert.org/ eSource: National Certification Corporation. (n.d.) Maintain your certification. Retrieved from http://www.nccwebsite.org/Certification-maintenance
(airway management, applied clinical pharmacology, human physiology and pathophysiology, and anesthesia equipment and technology) common to all nurse anesthetists regardless of practice setting could be assessed and periodically measured longitudinally. The NBCRNA sponsored a benchmarking study of several health care professions (See Table 1) to analyze practices in recertification (See Table 2). At the time of the study, the recertification cycle for nurse anesthetists was the shortest among the surveyed nursing professions. Nurse anesthetists recertified every 2 years, whereas nurse midwives and nurse practitioners recertified every 3 to 5 years. The recertification cycles for other health and physician providers ranged from 5 to 10 years. Direct comparison of CE requirements across health care professions is complicated because of the variance in the recertification cycle length. To facilitate analysis, the researchers standardized the CE requirements for each profession to hours and years. Among the three groups of health care professionals reviewed, those specializing in anesthesia ranked at or near the top of each individual group for most CE hours required per year. Of the 12 recertification programs reviewed, nine (75%) made use of a recertification examination, and three (25%) did not. Of the nine programs using recertification examinations, seven required the examination for recertification, and two had an examination as an option for recertification. Of the three programs that did not require a recertification examination, one (certified nurse midwives) planned to require an examination in the future. Of the 12 health care fields reviewed, five (42%) had professional work requirements for relicensure, and seven (58%) did not. Two of the three (67%) nursing specialties required practice hours as a condition of recertification. Of the five fields that had professional work requirements, three had a minimum number of practice hours required, and two required other means of verifying practice.
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The NBCRNA conducted a review of 60 medical and scientific resources from the past 30 years. In the literature, several concepts emerged: the growth of evidence-based practice, the exponential increase in medical knowledge, changes in credentialing requirements, the evolution of competency-based education and practice, assessment, and the need to move toward continuing competence. The research demonstrated consistent evidence across multiple sources in support of changes to the recertification program for nurse anesthetists.
Evolution of the Recertification Program In 2010, the NBCRNA formed a recertification task force (RTF) with CRNAs representative of the demographic and practice diversity of the profession. The RTF also included a CRNA representative appointed by the AANA Board of Directors. The RTF was charged with analyzing the data compiled during the research initiative and developing a plan for a revised recertification program for nurse anesthetists. The RTF developed definitions for the terms continuing competence and stakeholders. “Continuing competence, and thus continuing professional certification, in nurse anesthesia is an ongoing, multimodal, and iterative process focused on safe and effective care” (Plaus, 2011, p. 415). Stakeholders included the different groups with an interest in the recertification of nurse anesthetists. Identified stakeholder groups included the public, patients, families, anesthesiologists, other physicians, hospitals, other employers, regulatory bodies, continuing education program providers, NBCRNA certificants, and the AANA membership. On the basis of data compiled, the focus for continuing competence began to shift from initial certification and CE to lifelong learning—the continuous development of knowledge, skills, and abilities.
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Component
Definition
Start date
January 1, 2015
Length of cycle
4 years
Initial certification and licensure
Valid registered nursing or advanced nursing practice license
Work, practice
At least 425 hours per year in nurse anesthesia work practice
CE requirement
15 credits per year in assessed CE
Nonassessed activities
20 credits per year (80 per 4-year cycle)
CPC Modules
NBCRNA requires four core competency modules in every recertification cycle, one in each of four core competency areas
tee proposed modifications to address the major concerns of the stakeholders while maintaining the patient safety goals of the original proposal. Stakeholder concerns included cost, time, professional practice requirements, recertification testing, and re-entry into practice. To evaluate the potential modifications further and to solicit additional recommendations, the committee convened a group of subject matter experts to serve as an expert panel. The subject matter experts were nurse anesthetists who were leaders in certification, education, and practice development. They reviewed the original program and proposed modifications. First released for comment in August 2011, the CPC program was significantly revised four times between 2011 and 2015 based on input from the certificants and the AANA. The summary of evolution of CPC program changes from 2011 to 2014 appears in Table 4.
Examination
Every 8 years (during the second 4-year recertification cycle) First completion by December 31, 2023
CPC Program Goals and Components
Core competencies
Four core competency areas identified
Enhanced competencies
Six enhanced competencies identified
TABLE 3
Original CPC Program Proposed in 2011
Note. CE = continuing education; CPC = continued professional certification program; NBCRNA = National Board of Certification and Recertification for Nurse Anesthetists.
CPC Program: 2011 to 2015 In May 2011, the RTF submitted an initial proposal for the CPC program to the NBCRNA Board of Directors. In August 2011, it was revised and approved for open comment by the board and nurse anesthetists. The proposed program (See Table 3) was presented to certificants for a 3-month period of open comment between September 6 and November 14, 2011. At the outset of the public comment period, the NBCRNA stated that input would be used to inform, improve, supplement, refine, or even remove program elements before final board approval. During the public comment period, all CRNAs and stakeholders were encouraged to either complete a survey or contact the NBCRNA directly to provide feedback. Over the 3-month public comment period, the NBCRNA received approximately 4,200 survey responses, 920 e-mails, 280 questions via the CPC blog (Tumblr), and 900 phone calls. During the CPC public comment period, NBCRNA board members and staff presented the program at 32 state meetings, with a total audience of approximately 4,150, including CRNAs and other stakeholders. The presenters answered questions about the program’s goals and components and listened to comments, suggestions, and concerns. CPC Committee
To manage the revision process, NBCRNA appointed the CPC committee of CRNAs to review stakeholder input. The commit34
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The program is a multimodal recertification endeavor. It consists of a series of 8-year periods, each consisting of two 4-year cycles. Each cycle has the same requirements except that the second of the two cycles in each 8-year period contains the CPC examination. Goals
The goals of the CPC program are as follows: ⦁ Provide a framework for ensuring that the areas of nurse anesthesia measured are essential, regardless of practice setting, patients, and conditions ⦁ Support the expanding role of advanced practice registered nurses (APRNs) in the future of health care delivery and leadership by including the opportunity to report professional development activities ⦁ Use core modules to provide a means for nurse anesthetists to become familiar with new evidence that informs their immediate practice ⦁ Provide flexibility in how nurse anesthetists can meet continuing certification and professional development requirements. Components
The program requires 100 credits over 4 years—60 class A credits and 40 class B credits. This requirement represents five credits more per year than in the previous 2-year recertification program. The program provides a great deal of flexibility in the use of professional development activities and CE to meet these credits. The program introduced the novel requirements of class B credits, core modules, and the CPC examination. Class B credits allow the CRNA to count professional activities toward continuing certification. The core modules provide nurse anesthetists with contemporary evidence-based content in the four common areas. The CPC examination will be phased in over 16 years (See Table 5).
TABLE 4
Summary of Evolution of CPC Program Changes, 2011–2014 Initial program (August 2011)
Changes in current program (December 2014)
Length of cycle
Two 4-year cycles
Two 4-year cycles
Start date
January 1, 2015
August 1, 2016
Certification and licensure
Recertification is contingent on having initial certification and a current and valid registered nursing or advanced nursing practice license as a certified registered nurse anesthetist by NBCRNA or its predecessors
Recertification is contingent on having initial certification and a current and valid registered nursing or advanced nursing practice license as a certified registered nurse anesthetist by NBCRNA or its predecessors
Work, practice
Documentation of at least 425 hours per year in nurse anesthesia work practice with requirements for individuals who do not document compliance with the professional work practice requirement
Requirement for a specified number of hours removed
CE requirement: 15 credits per year in assessed CE assessed
15 credits per year in assessed CE Allows (assessed) life support courses to be reported AANA CE Committee to develop assessed CE criteria The term class A credits introduced at AANA’s request
CE requirement: 20 credits per year in nonassessed educational activities nonassessed
10 credits per year in nonassessed educational activities Allows life support courses to be reported Professional Activity Units changed to class B credits at AANA’s request
CPC modules
Four core modules in every 4-year CPC cycle, one module in each of the four core competency areas
CPC core modules will be voluntary for the first 4-year cycle Modules provide assessed CE credits Module delivery mode expanded beyond Web only Module CE caps removed
Examination
Successful completion of a standardized recertification examination every 8 years (at any time during the second 4-year recertification cycle)
Pass/fail examination phased in over 20 years (passing standard moved from 2023 to 2032) Examination in the first 8-year interval requires meeting a performance standard Options to be explored beyond taking a CPC module if a performance standard is not met on the first CPC examination
Re-entry program
If more than 90 days have transpired, individuals will be required to satisfy the eligibility criteria for recertification at the time of their reapplication as well as apply for and pass the entry-level National Certification Examination
Complete 4-year CPC cycle requirements and take CPC examination; complete activities in an accredited simulation center; evidence of employment in nurse anesthesia within 12 months of completing first two requirements
Note. AANA = American Association of Nurse Anesthetists; CE = continuing education; CPC = continued professional certification program; NBCRNA = National Board of Certification and Recertification for Nurse Anesthetists.
The program’s 4-year recertification cycles are consistent with Accreditation Board for Specialty Nursing Certification requirements that recertification periods be no more than 5 years. The NCSBN (2008) APRN Consensus Model also requires that recertification take place every 5 years or sooner. License and Practice Requirement
Every 2 years, nurse anesthetists will verify that their license is current. The NBCRNA no longer prescribes a minimum number of practice hours to maintain CPC compliance. State boards of nursing (or their regulatory equivalent) and facility credentialing bodies often determine specific practice-hour requirements for practitioners and establish compliance requirements at the state or institutional level. For the purposes of CPC compliance, active Volume 8/Issue 1 April 2017
anesthesia practice can be reported in areas of clinical practice, education, research, or administration. Class A Credits: Lifelong Learning and Continued Competence
Class A activities are CE programs related to nurse anesthesia that have an assessment and are previously approved by an appropriate entity. The content must be related to the delivery of anesthesia care or to the improvement of the delivery of anesthesia care. Because the scope of practice of nurse anesthesia is broad, this requirement can include clinical content as well as practice, research, and professional development. The assessment is a valuable tool in the process of lifelong learning, helping identify areas mastered as well as areas for future learning. An assessment can take many forms, depending on the www.journalofnursingregulation.com
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TABLE 5
CPC Program Cycle
Timeline Requirements
Total Cycle
4-year cycle
2016– 2020
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules optional
8-year CPC period
4-year cycle
2020– 2024
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules CPC examination: meet performance standard
4-year cycle
2024– 2028
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules
4-year cycle
2028– 2032
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules CPC examination: meet passing standard
8-year CPC period
Note. CPC = continued professional certification program.
TABLE 6
A Partial List of Class B Credits ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁
Class A credits CE not previously approved Nonassessed CE Presentations Peer review of publications Publications related to nursing Teaching in the clinical setting Administrative roles in the clinic Service in committee Mission work Advocacy Research or practice inquiry
Note. CE = continuing education.
educational activity. Self-assessment, demonstrations, polling, case studies, simulations, and posttests are all valid forms of assessment. Class B Credits: Professional Development
Nurse anesthetists engage in many professional activities and participate in practice-related opportunities consistent with practice and career needs (See Table 6). By including professional development activities (class B requirements), the CPC program supports the expanding role of APRNs in the future of health care delivery and leadership. The program requires 40 class B credits every 4 years. Many CRNAs are already engaged in class B credits as a condition of employment, licensure, or other activities. The list of professional development activities that will satisfy the class 36
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B requirements is broad and likely to grow after the program is underway. Existing state mandated registered nurse and APRN licensing requirements, such as infection control, pain management, and communication, may also meet class B requirements. Core Modules: Evidence-Based Practice and Knowledge
The core modules provide a structured approach for nurse anesthetists to stay abreast of current evidence and emerging knowledge not documented in standard textbooks. The modules consist of new evidence that informs clinical practice in the four content areas of airway management, applied clinical pharmacology, human physiology and pathophysiology, and anesthesia equipment and technology. CPC Examination: Periodic Measurement of Continued Competence
The CPC examination will focus on the knowledge clinical CRNAs attain over time through clinical practice, CE, and evidence-based literature and will assess knowledge and skills reasonably experienced nurse anesthetists must maintain throughout their careers regardless of practice setting. The examination consists of the same four core content areas of nurse anesthesia practice represented in the core modules. The first CPC examination will give nurse anesthetists the opportunity to become familiar with the core content, experience an electronic testing format, and identify areas in need of additional study. To meet the program requirements, CRNAs will need to meet a performance standard for the first CPC examination. If the performance standard is not met in any content area, the CRNA will take an additional core module for each area. CRNAs will not lose their certification based solely on the performance standard examination if they complete all other CPC requirements and any additional core module requirements by the CPC compliance date. The second examination will be like the first examination and will require meeting a passing standard. A CRNA who does not meet the passing standard on the examination will have up to four opportunities during the 4-year cycle to complete the examination with a passing score. The NBCRNA does not report individual examination scores to any licensing body. NBCRNA only reports CPC compliance status.
Lessons Learned The redesign of the NBCRNA recertification program had two phases: development and implementation. The former was a datadriven process designed to provide evidence and rationale for change and to design and revise the program. The latter was a human-focused process designed to inform certificants and others that change was needed and to add value to the credential. Important lessons learned during the 7-year process include transparency, translation, communication, collaboration, and coordination.
The redesign of recertification must be an open process. An organization should engage stakeholders at the outset and throughout program modifications. The data-driven development phase produces information that the organization analyzes and uses for decision making. Throughout this process, the data should be contextualized for the stakeholders and regularly disseminated using a variety of methods. Certificants should be able to understand and consider the data over time, so they recognize the redesigned program as evidence based when it is introduced. At each point in the process, the organization must reach out to stakeholders, involve them in discussion, ask them for comment and input, and expose them to data. Open pathways for communication with the organization and documentation of the exchanges and their impact on program planning are important throughout the process. An organization considering the redesign of its recertification program should have a plan for the processes of development and implementation. These two plans must be interdependent. The process of development should anticipate the challenges inherent in implementing a redesigned program, and the implementation phase should reference the communications, transparency, and translational activities produced during the planning stages. Establishing an overall plan for the process allows an organization to focus on the task at hand while setting expectations for stakeholders.
Conclusion The CPC program demonstrates an increased accountability to the public, patients, and other stakeholders. As nurse anesthetists face competitive challenges from other professions, the increased rigor of the credential enhances its value to employers, the public, and other professionals who expect a credential that documents lifelong learning and evidence-based practice. The introduction of the new program components allows nurse anesthetists flexibility and the opportunity for an individualized continued certification program. The program supports the nurse anesthetist’s ability to identify gaps in knowledge and skills through assessed CE and periodic examinations and to maintain a core of evidence-based knowledge through core modules. NBCRNA will establish an ongoing evaluation of the program components based on evidence accumulated through each cycle and make program modifications as needed.
Citizen Advocacy Center. (2004). Maintaining and improving health professional competence: The Citizen Advocacy Center road map to continuing competency assurance. Washington, DC: Author. Retrieved from www. cacenter.org Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association, 122, 48–58. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century (p. 1). Washington, DC: The National Academies Press. Institute of Medicine: Committee on the Health Professions Education Summit. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press. Institute of Medicine. (2009). Redesigning continuing education in the health professions. Washington, DC: The National Academies Press. National Board of Certification and Recertification for Nurse Anesthetists, Citizen Advocacy Center. (2013). Public Survey on Healthcare Providers [Press release]. Retrieved from http://www.nbcrna.com/ about-us/news_archive/Pages/Press-Release-Public-Survey-onHealthcare-Providers.aspx National Board of Certification and Recertification for Nurse Anesthetists. (2014). NBCRNA continued professional certification (CPC) program: Evolution and development, 2008-2014. Retrieved from http:// www.nbcrna.com/cpc/Documents/CPC_Report_Evolution_and_ Development_2008-2014.pdf National Council of State Boards of Nursing. (n.d.). Meeting the ongoing challenge of continued competence. Retrieved from http://www.ncsbn. org/pdfs/Continued_Comp_Paper_TestingServices.pdf National Council of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education July 7, 2008. Retrieved from https://www.ncsbn.org/Consensus_Model_ for_APRN_Regulation_July_2008.pdf Plaus, K., Muckle, T. J., Henderson, J. P. (2011). Advancing recertification for nurse anesthetists in an environment of increased accountability. AANA Journal, 79(5), 413–418. Retrieved from http://www. aana.com/newsandjournal/Documents/advrecert_1011_p413-418. pdf
Steve Wooden, DNP, CRNA, NSPM-C, is President of the National Board of Certification and Recertification for Nurse Anesthetists, Albion, Nebraska. Mary Anne Krogh, PhD, CRNA, is Past President, National Board of Certification and Recertification for Nurse Anesthetists, Sioux Falls, South Dakota. Ed Waters, CRNA, DNP, is Past President, National Board of Certification and Recertification for Nurse Anesthetists, Pasadena, California. Karen Plaus, PhD, CRNA, FAAN, CAE, is CEO, National Board of Certification and Recertification for Nurse Anesthetists, Chicago, Illinois.
References American Association of Nurse Anesthetists. (n.d.) Timeline of AANA history. Retrieved from http://www.aana.com/resources2/archiveslibrary/Pages/Timeline-of-AANA-History.aspx American Association of Retired Persons. (2007). Strategies to improve health care quality in Virginia: Survey of residents age 50+, 2007 knowledge management. Washington, DC: Author. (2007). Retrieved from http://www.aarp.org/research
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Keywords: Continued competence, nurse anesthetists, professional development, recertification
I
n 1969, the American Association of Nurse Anesthetists (AANA) adopted continuing education (CE) as a voluntary component for recertification. In 1978, it became a requirement. The recertification program required nurse anesthetists to complete a minimum of 40 hours of CE, attest to a minimum number of practice hours, and maintain nursing licensure. The recertification program remained in place without substantial modifications until 2016 (AANA, n.d.). A compelling argument for changing a program of 40 years must answer critical questions: ⦁ What has changed in and around the profession to warrant changing the recertification process for nurse anesthetists? ⦁ Will changes to the recertification process add value to a nurse anesthetist’s credential? To answer these questions, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) undertook a 3-year research initiative to identify best practices and trends in health professions education and a 4-year period of review and modification.
Influences Literature
The Institute of Medicine’s (IOM’s) 2001 report, Crossing the Quality Chasm, found that despite the rapid advance in medicine and technology, the health care system “frequently falls short in its ability Volume 8/Issue 1 April 2017
to translate knowledge into practice and to apply new technology safely and appropriately” (Institute of Medicine, 2001, 2, 3). The report recommended that CE emphasize a variety of approaches and a focus on evidence-based practice. As the report noted, “responsibility for assessing competence is dispersed among multiple authorities,” such as licensing boards, employers, professional societies, and accreditation groups, but “no consistent methods for ensuring continued competence of health professionals” exists (Institute of Medicine, 2001, p. 217). The IOM published a follow-up report in 2003, Health Professions Education: A Bridge to Quality, which called on health care profession boards to require periodic demonstrations of competence through assessment (Institute of Medicine, 2003, p. 13). The 2009 IOM study, Redesigning Continuing Education in the Health Professions, cited “major flaws in the way [CE] is conducted, financed, regulated, and evaluated” (Institute of Medicine, 2009, p. 6). The IOM report suggested that a vision of professional development was needed to focus the process on lifelong learning, including assessment and measurement of continued competence (Institute of Medicine, 2009, p. 38). In 2011, the Robert Wood Johnson Foundation and the IOM published the results of a 2-year study of the nursing profession. The report, The Future of Nursing: Leading Change, Advancing Health (Committee on the Robert Wood Johnson Foundation Initiative, 2011), identified the need for nurses to establish, maintain, and expand new competencies during their education and www.journalofnursingregulation.com
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TABLE 1
Professions Surveyed for Benchmarking Advanced Practice Nurses Nurse anesthetists Certified nurse midwives Nurse practitioners Independent Health Care Providers Anesthesiologists Medical examiners Optometrists Pharmacists Podiatrists Other Dependent Health Care Providers Anesthesiologist assistants Occupational therapists Physical therapists Physician assistants
throughout their career. The report recommended “accrediting, licensing, and certifying organizations’ need to mandate demonstrated mastery of core skills and competencies to complement the completion of degree programs and written board examinations” (Committee on the Robert Wood Johnson Foundation Initiative, 2011, p. 163). In 2005, the National Council of State Boards of Nursing (NCSBN) published a concept paper that identified the need for ongoing maintenance of continued competence (n.d.). In 2007, the American Board of Nursing Specialties Accreditation Council, now known as the Accreditation Board for Specialty Nursing Certification, implemented a requirement that recertification programs must have certificants demonstrate maintenance of knowledge over time and provide documentation showing how competence in the specialty is maintained over time. A more extensive review of the literature supporting the continued professional certification (CPC) program can be found in the document, NBCRNA Continued Professional Certification (CPC) Program: Evolution and Development, 2008-2014 (NBCRNA, 2014). Growth in Knowledge, Technology, and Skills
Health care knowledge is expanding rapidly. Densen (2011) estimated the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020, it is projected to be just 73 days. Nurse anesthetists who entered practice when recertification became a requirement have seen extraordinary changes in equipment, technology, and pharmacology. The first nurse anesthetists earned a certificate after completing a mentoring program in a hospital-based course of study. This approach evolved into a diploma program and, eventually, entry-into-practice education required a bachelor’s degree. By the 1990s, the educational requirement for entry level nurse anesthetists was a master’s degree. By 2016, approximately one-third of nurse anesthesia programs provide a doctoral degree for entry into practice, and all programs are required to be in a doctoral frame32
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work by 2022 (AANA, n.d.). Nurse anesthetists entering the profession today are educated to work in an increasingly complex and interdisciplinary practice environment. Although the education requirements for entry into practice have kept pace with changing healthcare needs, the recertification process for nurse anesthetists has not. Stakeholder Input
NBCRNA stakeholder groups include the public, patients, patients’ families, anesthesiologists, other physicians, hospital representatives, other employers, representatives of regulatory bodies, CE program providers, NBCRNA certificants, and representatives of the AANA. The stakeholders were included in the research initiative through literature reviews, surveys, and direct input at various stages in the process. In 2004, the Citizen Advocacy Center published Maintaining and Improving Health Profession Competence: The Citizen Advocacy Center Road Map to Continuing Competency Assurance, which argued that assurances of continuing competence of health care practitioners is an essential element of any program to improve patient safety and health care quality (Citizen Advocacy Center, 2004, p. i). This group called for reform of CE programs to ensure the continued competence of health professionals and periodic continuing competency assessment. In 2007, the American Association of Retired Persons (AARP) conducted a public opinion poll that sought to identify the perceived value of CE and assessment. The AARP reported that 80% of respondents indicated the importance of clinicians passing periodic examinations. Further, 95% indicated that doctors, nurses, and other health care professionals should be required to periodically demonstrate continued competence (AARP 2007). In 2011, Harris Interactive conducted a poll on behalf of the NBCRNA and the Citizen Advocacy Center to gain a better understanding of the public’s perspective on the credentialing standards required of their health care providers. The responses indicated that the public prefers that providers participate in a multimodal recertification program that includes periodic assessment of knowledge and lifelong evidence-based learning (NBCRNA, 2013).
Research: 2008 to 2011 In 2008, the NBCRNA conducted a professional practice analysis (PPA), targeting all NBCRNA-certified registered nurse anesthetists (CRNAs) eligible for recertification. The PPA focused on the practice of nurse anesthesia at a level more advanced than expected for initial certification. The core knowledge required of nurse anesthetists regardless of practice setting, patient profile, and work conditions was identified. The PPA was developed through a multistep process, including input from an appointed committee charged with analysis of the results. This process indicated that four core domains
TABLE 2
Benchmarking Recertification Requirements Among Medical Professions in 2008 Recertification components Nurse anesthetists
Frequency (y)
Current licensure
2
Yes
Continuing education (h) Periodic assessment
Practice
40
NA
850 hours
Anesthesiologist assistantsa
2
NA
40
Yes; 6 years
Not required
Anesthesiologists (MDs)b
10
Yes
350
Yes
Yes
midwivesc
5
Yes
20 (3 modules)
Proposed
Not required
5
Yes
25
Optional
1,000 hours
3
Yes
15–50
Yes
Not required
Certified nurse
Nurse practitioners (AANP)d Nurse practitioners
(NCC)e
Note. AANP = American Academy of Nurse Practitioners; MD = allopathic physician; NA = not applicable; NCC = National Certification Corporation. aSource: American Academy of Anesthesiologist Assistants. (n.d.). Frequently asked questions. Retrieved from http://www.anesthetist.org/faqs#recertify bSource: American Board of Anesthesiology. (n.d.). About MOCHA 2.0. Retrieved from http://www.theaba.org/MOCA/About-MOCA-2-0 cSource: American Midwifery Certification Board. (n.d.). Certificate maintenance program. Retrieved from http://www.amcbmidwife.org/certificate-maintenance-
program dSource: American Academy of Nurse Practitioners. (n.d.) American Academy of Nurse Practitioners Certification Board. Retrieved from http://www.aanpcert.org/ eSource: National Certification Corporation. (n.d.) Maintain your certification. Retrieved from http://www.nccwebsite.org/Certification-maintenance
(airway management, applied clinical pharmacology, human physiology and pathophysiology, and anesthesia equipment and technology) common to all nurse anesthetists regardless of practice setting could be assessed and periodically measured longitudinally. The NBCRNA sponsored a benchmarking study of several health care professions (See Table 1) to analyze practices in recertification (See Table 2). At the time of the study, the recertification cycle for nurse anesthetists was the shortest among the surveyed nursing professions. Nurse anesthetists recertified every 2 years, whereas nurse midwives and nurse practitioners recertified every 3 to 5 years. The recertification cycles for other health and physician providers ranged from 5 to 10 years. Direct comparison of CE requirements across health care professions is complicated because of the variance in the recertification cycle length. To facilitate analysis, the researchers standardized the CE requirements for each profession to hours and years. Among the three groups of health care professionals reviewed, those specializing in anesthesia ranked at or near the top of each individual group for most CE hours required per year. Of the 12 recertification programs reviewed, nine (75%) made use of a recertification examination, and three (25%) did not. Of the nine programs using recertification examinations, seven required the examination for recertification, and two had an examination as an option for recertification. Of the three programs that did not require a recertification examination, one (certified nurse midwives) planned to require an examination in the future. Of the 12 health care fields reviewed, five (42%) had professional work requirements for relicensure, and seven (58%) did not. Two of the three (67%) nursing specialties required practice hours as a condition of recertification. Of the five fields that had professional work requirements, three had a minimum number of practice hours required, and two required other means of verifying practice.
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The NBCRNA conducted a review of 60 medical and scientific resources from the past 30 years. In the literature, several concepts emerged: the growth of evidence-based practice, the exponential increase in medical knowledge, changes in credentialing requirements, the evolution of competency-based education and practice, assessment, and the need to move toward continuing competence. The research demonstrated consistent evidence across multiple sources in support of changes to the recertification program for nurse anesthetists.
Evolution of the Recertification Program In 2010, the NBCRNA formed a recertification task force (RTF) with CRNAs representative of the demographic and practice diversity of the profession. The RTF also included a CRNA representative appointed by the AANA Board of Directors. The RTF was charged with analyzing the data compiled during the research initiative and developing a plan for a revised recertification program for nurse anesthetists. The RTF developed definitions for the terms continuing competence and stakeholders. “Continuing competence, and thus continuing professional certification, in nurse anesthesia is an ongoing, multimodal, and iterative process focused on safe and effective care” (Plaus, 2011, p. 415). Stakeholders included the different groups with an interest in the recertification of nurse anesthetists. Identified stakeholder groups included the public, patients, families, anesthesiologists, other physicians, hospitals, other employers, regulatory bodies, continuing education program providers, NBCRNA certificants, and the AANA membership. On the basis of data compiled, the focus for continuing competence began to shift from initial certification and CE to lifelong learning—the continuous development of knowledge, skills, and abilities.
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Component
Definition
Start date
January 1, 2015
Length of cycle
4 years
Initial certification and licensure
Valid registered nursing or advanced nursing practice license
Work, practice
At least 425 hours per year in nurse anesthesia work practice
CE requirement
15 credits per year in assessed CE
Nonassessed activities
20 credits per year (80 per 4-year cycle)
CPC Modules
NBCRNA requires four core competency modules in every recertification cycle, one in each of four core competency areas
tee proposed modifications to address the major concerns of the stakeholders while maintaining the patient safety goals of the original proposal. Stakeholder concerns included cost, time, professional practice requirements, recertification testing, and re-entry into practice. To evaluate the potential modifications further and to solicit additional recommendations, the committee convened a group of subject matter experts to serve as an expert panel. The subject matter experts were nurse anesthetists who were leaders in certification, education, and practice development. They reviewed the original program and proposed modifications. First released for comment in August 2011, the CPC program was significantly revised four times between 2011 and 2015 based on input from the certificants and the AANA. The summary of evolution of CPC program changes from 2011 to 2014 appears in Table 4.
Examination
Every 8 years (during the second 4-year recertification cycle) First completion by December 31, 2023
CPC Program Goals and Components
Core competencies
Four core competency areas identified
Enhanced competencies
Six enhanced competencies identified
TABLE 3
Original CPC Program Proposed in 2011
Note. CE = continuing education; CPC = continued professional certification program; NBCRNA = National Board of Certification and Recertification for Nurse Anesthetists.
CPC Program: 2011 to 2015 In May 2011, the RTF submitted an initial proposal for the CPC program to the NBCRNA Board of Directors. In August 2011, it was revised and approved for open comment by the board and nurse anesthetists. The proposed program (See Table 3) was presented to certificants for a 3-month period of open comment between September 6 and November 14, 2011. At the outset of the public comment period, the NBCRNA stated that input would be used to inform, improve, supplement, refine, or even remove program elements before final board approval. During the public comment period, all CRNAs and stakeholders were encouraged to either complete a survey or contact the NBCRNA directly to provide feedback. Over the 3-month public comment period, the NBCRNA received approximately 4,200 survey responses, 920 e-mails, 280 questions via the CPC blog (Tumblr), and 900 phone calls. During the CPC public comment period, NBCRNA board members and staff presented the program at 32 state meetings, with a total audience of approximately 4,150, including CRNAs and other stakeholders. The presenters answered questions about the program’s goals and components and listened to comments, suggestions, and concerns. CPC Committee
To manage the revision process, NBCRNA appointed the CPC committee of CRNAs to review stakeholder input. The commit34
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The program is a multimodal recertification endeavor. It consists of a series of 8-year periods, each consisting of two 4-year cycles. Each cycle has the same requirements except that the second of the two cycles in each 8-year period contains the CPC examination. Goals
The goals of the CPC program are as follows: ⦁ Provide a framework for ensuring that the areas of nurse anesthesia measured are essential, regardless of practice setting, patients, and conditions ⦁ Support the expanding role of advanced practice registered nurses (APRNs) in the future of health care delivery and leadership by including the opportunity to report professional development activities ⦁ Use core modules to provide a means for nurse anesthetists to become familiar with new evidence that informs their immediate practice ⦁ Provide flexibility in how nurse anesthetists can meet continuing certification and professional development requirements. Components
The program requires 100 credits over 4 years—60 class A credits and 40 class B credits. This requirement represents five credits more per year than in the previous 2-year recertification program. The program provides a great deal of flexibility in the use of professional development activities and CE to meet these credits. The program introduced the novel requirements of class B credits, core modules, and the CPC examination. Class B credits allow the CRNA to count professional activities toward continuing certification. The core modules provide nurse anesthetists with contemporary evidence-based content in the four common areas. The CPC examination will be phased in over 16 years (See Table 5).
TABLE 4
Summary of Evolution of CPC Program Changes, 2011–2014 Initial program (August 2011)
Changes in current program (December 2014)
Length of cycle
Two 4-year cycles
Two 4-year cycles
Start date
January 1, 2015
August 1, 2016
Certification and licensure
Recertification is contingent on having initial certification and a current and valid registered nursing or advanced nursing practice license as a certified registered nurse anesthetist by NBCRNA or its predecessors
Recertification is contingent on having initial certification and a current and valid registered nursing or advanced nursing practice license as a certified registered nurse anesthetist by NBCRNA or its predecessors
Work, practice
Documentation of at least 425 hours per year in nurse anesthesia work practice with requirements for individuals who do not document compliance with the professional work practice requirement
Requirement for a specified number of hours removed
CE requirement: 15 credits per year in assessed CE assessed
15 credits per year in assessed CE Allows (assessed) life support courses to be reported AANA CE Committee to develop assessed CE criteria The term class A credits introduced at AANA’s request
CE requirement: 20 credits per year in nonassessed educational activities nonassessed
10 credits per year in nonassessed educational activities Allows life support courses to be reported Professional Activity Units changed to class B credits at AANA’s request
CPC modules
Four core modules in every 4-year CPC cycle, one module in each of the four core competency areas
CPC core modules will be voluntary for the first 4-year cycle Modules provide assessed CE credits Module delivery mode expanded beyond Web only Module CE caps removed
Examination
Successful completion of a standardized recertification examination every 8 years (at any time during the second 4-year recertification cycle)
Pass/fail examination phased in over 20 years (passing standard moved from 2023 to 2032) Examination in the first 8-year interval requires meeting a performance standard Options to be explored beyond taking a CPC module if a performance standard is not met on the first CPC examination
Re-entry program
If more than 90 days have transpired, individuals will be required to satisfy the eligibility criteria for recertification at the time of their reapplication as well as apply for and pass the entry-level National Certification Examination
Complete 4-year CPC cycle requirements and take CPC examination; complete activities in an accredited simulation center; evidence of employment in nurse anesthesia within 12 months of completing first two requirements
Note. AANA = American Association of Nurse Anesthetists; CE = continuing education; CPC = continued professional certification program; NBCRNA = National Board of Certification and Recertification for Nurse Anesthetists.
The program’s 4-year recertification cycles are consistent with Accreditation Board for Specialty Nursing Certification requirements that recertification periods be no more than 5 years. The NCSBN (2008) APRN Consensus Model also requires that recertification take place every 5 years or sooner. License and Practice Requirement
Every 2 years, nurse anesthetists will verify that their license is current. The NBCRNA no longer prescribes a minimum number of practice hours to maintain CPC compliance. State boards of nursing (or their regulatory equivalent) and facility credentialing bodies often determine specific practice-hour requirements for practitioners and establish compliance requirements at the state or institutional level. For the purposes of CPC compliance, active Volume 8/Issue 1 April 2017
anesthesia practice can be reported in areas of clinical practice, education, research, or administration. Class A Credits: Lifelong Learning and Continued Competence
Class A activities are CE programs related to nurse anesthesia that have an assessment and are previously approved by an appropriate entity. The content must be related to the delivery of anesthesia care or to the improvement of the delivery of anesthesia care. Because the scope of practice of nurse anesthesia is broad, this requirement can include clinical content as well as practice, research, and professional development. The assessment is a valuable tool in the process of lifelong learning, helping identify areas mastered as well as areas for future learning. An assessment can take many forms, depending on the www.journalofnursingregulation.com
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TABLE 5
CPC Program Cycle
Timeline Requirements
Total Cycle
4-year cycle
2016– 2020
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules optional
8-year CPC period
4-year cycle
2020– 2024
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules CPC examination: meet performance standard
4-year cycle
2024– 2028
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules
4-year cycle
2028– 2032
Valid license; practice requirement 60 class A credits and 40 class B credits required; core modules CPC examination: meet passing standard
8-year CPC period
Note. CPC = continued professional certification program.
TABLE 6
A Partial List of Class B Credits ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁
Class A credits CE not previously approved Nonassessed CE Presentations Peer review of publications Publications related to nursing Teaching in the clinical setting Administrative roles in the clinic Service in committee Mission work Advocacy Research or practice inquiry
Note. CE = continuing education.
educational activity. Self-assessment, demonstrations, polling, case studies, simulations, and posttests are all valid forms of assessment. Class B Credits: Professional Development
Nurse anesthetists engage in many professional activities and participate in practice-related opportunities consistent with practice and career needs (See Table 6). By including professional development activities (class B requirements), the CPC program supports the expanding role of APRNs in the future of health care delivery and leadership. The program requires 40 class B credits every 4 years. Many CRNAs are already engaged in class B credits as a condition of employment, licensure, or other activities. The list of professional development activities that will satisfy the class 36
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B requirements is broad and likely to grow after the program is underway. Existing state mandated registered nurse and APRN licensing requirements, such as infection control, pain management, and communication, may also meet class B requirements. Core Modules: Evidence-Based Practice and Knowledge
The core modules provide a structured approach for nurse anesthetists to stay abreast of current evidence and emerging knowledge not documented in standard textbooks. The modules consist of new evidence that informs clinical practice in the four content areas of airway management, applied clinical pharmacology, human physiology and pathophysiology, and anesthesia equipment and technology. CPC Examination: Periodic Measurement of Continued Competence
The CPC examination will focus on the knowledge clinical CRNAs attain over time through clinical practice, CE, and evidence-based literature and will assess knowledge and skills reasonably experienced nurse anesthetists must maintain throughout their careers regardless of practice setting. The examination consists of the same four core content areas of nurse anesthesia practice represented in the core modules. The first CPC examination will give nurse anesthetists the opportunity to become familiar with the core content, experience an electronic testing format, and identify areas in need of additional study. To meet the program requirements, CRNAs will need to meet a performance standard for the first CPC examination. If the performance standard is not met in any content area, the CRNA will take an additional core module for each area. CRNAs will not lose their certification based solely on the performance standard examination if they complete all other CPC requirements and any additional core module requirements by the CPC compliance date. The second examination will be like the first examination and will require meeting a passing standard. A CRNA who does not meet the passing standard on the examination will have up to four opportunities during the 4-year cycle to complete the examination with a passing score. The NBCRNA does not report individual examination scores to any licensing body. NBCRNA only reports CPC compliance status.
Lessons Learned The redesign of the NBCRNA recertification program had two phases: development and implementation. The former was a datadriven process designed to provide evidence and rationale for change and to design and revise the program. The latter was a human-focused process designed to inform certificants and others that change was needed and to add value to the credential. Important lessons learned during the 7-year process include transparency, translation, communication, collaboration, and coordination.
The redesign of recertification must be an open process. An organization should engage stakeholders at the outset and throughout program modifications. The data-driven development phase produces information that the organization analyzes and uses for decision making. Throughout this process, the data should be contextualized for the stakeholders and regularly disseminated using a variety of methods. Certificants should be able to understand and consider the data over time, so they recognize the redesigned program as evidence based when it is introduced. At each point in the process, the organization must reach out to stakeholders, involve them in discussion, ask them for comment and input, and expose them to data. Open pathways for communication with the organization and documentation of the exchanges and their impact on program planning are important throughout the process. An organization considering the redesign of its recertification program should have a plan for the processes of development and implementation. These two plans must be interdependent. The process of development should anticipate the challenges inherent in implementing a redesigned program, and the implementation phase should reference the communications, transparency, and translational activities produced during the planning stages. Establishing an overall plan for the process allows an organization to focus on the task at hand while setting expectations for stakeholders.
Conclusion The CPC program demonstrates an increased accountability to the public, patients, and other stakeholders. As nurse anesthetists face competitive challenges from other professions, the increased rigor of the credential enhances its value to employers, the public, and other professionals who expect a credential that documents lifelong learning and evidence-based practice. The introduction of the new program components allows nurse anesthetists flexibility and the opportunity for an individualized continued certification program. The program supports the nurse anesthetist’s ability to identify gaps in knowledge and skills through assessed CE and periodic examinations and to maintain a core of evidence-based knowledge through core modules. NBCRNA will establish an ongoing evaluation of the program components based on evidence accumulated through each cycle and make program modifications as needed.
Citizen Advocacy Center. (2004). Maintaining and improving health professional competence: The Citizen Advocacy Center road map to continuing competency assurance. Washington, DC: Author. Retrieved from www. cacenter.org Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association, 122, 48–58. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century (p. 1). Washington, DC: The National Academies Press. Institute of Medicine: Committee on the Health Professions Education Summit. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press. Institute of Medicine. (2009). Redesigning continuing education in the health professions. Washington, DC: The National Academies Press. National Board of Certification and Recertification for Nurse Anesthetists, Citizen Advocacy Center. (2013). Public Survey on Healthcare Providers [Press release]. Retrieved from http://www.nbcrna.com/ about-us/news_archive/Pages/Press-Release-Public-Survey-onHealthcare-Providers.aspx National Board of Certification and Recertification for Nurse Anesthetists. (2014). NBCRNA continued professional certification (CPC) program: Evolution and development, 2008-2014. Retrieved from http:// www.nbcrna.com/cpc/Documents/CPC_Report_Evolution_and_ Development_2008-2014.pdf National Council of State Boards of Nursing. (n.d.). Meeting the ongoing challenge of continued competence. Retrieved from http://www.ncsbn. org/pdfs/Continued_Comp_Paper_TestingServices.pdf National Council of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education July 7, 2008. Retrieved from https://www.ncsbn.org/Consensus_Model_ for_APRN_Regulation_July_2008.pdf Plaus, K., Muckle, T. J., Henderson, J. P. (2011). Advancing recertification for nurse anesthetists in an environment of increased accountability. AANA Journal, 79(5), 413–418. Retrieved from http://www. aana.com/newsandjournal/Documents/advrecert_1011_p413-418. pdf
Steve Wooden, DNP, CRNA, NSPM-C, is President of the National Board of Certification and Recertification for Nurse Anesthetists, Albion, Nebraska. Mary Anne Krogh, PhD, CRNA, is Past President, National Board of Certification and Recertification for Nurse Anesthetists, Sioux Falls, South Dakota. Ed Waters, CRNA, DNP, is Past President, National Board of Certification and Recertification for Nurse Anesthetists, Pasadena, California. Karen Plaus, PhD, CRNA, FAAN, CAE, is CEO, National Board of Certification and Recertification for Nurse Anesthetists, Chicago, Illinois.
References American Association of Nurse Anesthetists. (n.d.) Timeline of AANA history. Retrieved from http://www.aana.com/resources2/archiveslibrary/Pages/Timeline-of-AANA-History.aspx American Association of Retired Persons. (2007). Strategies to improve health care quality in Virginia: Survey of residents age 50+, 2007 knowledge management. Washington, DC: Author. (2007). Retrieved from http://www.aarp.org/research
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