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Certification--good for business.

Dialysis is big business. In 2010 (the most recent data available), total Medicare spending rose to $522.8 billion, with spending for end stage renal disease (ESRD) rising 8% over 2009 spending to $32.9 billion. This spending covered 488,938 patients in the prevalent Medicare ESRD population along with 105,436 non-Medicare patients with ESRD. Non-Medicare patients cost an additional estimated $14.5 billion (U.S. Renal Data System [USRDS], 2012).

The exact costs and numbers associated with chronic kidney disease (CKD) treatment are more difficult to determine. Since CKD is often associated with cardiovascular disease, diabetes, stroke, and infectious complications, the specific diagnosis of CKD is probably significantly under-reported. Using prevalent data, the combined CKD and ESRD populations currently account for 24% of the Medicare budget (USRDS, 2012).

Acute kidney injury (AKI) also shows a rising incidence, but there is difficulty in isolating the diagnosis. Data indicate that 58% of patients with an AKI hospitalization experience a recurrent AKI hospitalization within one year (USRDS, 2012). The risk of recurrent hospitalization is increased by the pre-existence of CKD. AKI is highly associated with age. In 2010, Medicare patients age 66 to 69 had a rate of AKI of 13.6% per 1,000 patient years, 18.1% for patients 70 to 74 years of age, and 24.9% for patients 75 to 79 years of age (USRDS, 2012). Patients tend to have an increase in their CKD stage following an AKI hospitalization (USRDS, 2012). Further, those surviving an AKI episode are at risk of developing ESRD (USRDS, 2012). In fact, of patients with Stage 3 to 5 CKD pre-hospitalization, 62% reach ESRD (USRDS, 2012) following an episode of AKI.

This is not only an American problem. Around the globe, approximately two million people receive regular dialysis. The number of patients is likely to double over the coming decade. Many will be in developing countries where improving income levels are increasing demand for treatment where none would have been offered previously (The Economist, 2010).

Future Challenges

It is predicted that by the year 2030, 20% of the United States population will be 65 years of age or older (U.S. Census Bureau, 2012). It is clear that the industry of dialysis covers the complete life span of patients with a varied spectrum of treatment modalities who experience increasing risk of disease as they age. The demand for quality health care, and therefore, quality nursing care, is not showing any signs of declining. Instead, the arrival of the Baby Boomer generation at retirement age and in need of increased health care due to aging corresponds with the impending retirement of nurses who are also a part of that same generation (Atencio, Cohen, & Gorenberg, 2003). Baby Boomers currently comprise 40% of the current healthcare workforce, so with their anticipated retirement, there will be a drastic reduction in the supply of registered nurses (Juraschek, Zhang, Ranganathan, & Lin, 2012).

A study by the Greater Cincinnati Health Council (Yablonsky, 2012) found that over 16% of the region's registered nurses (RNs) are 55 years of age and older, creating an anticipated shortage of nurses in the near future. A government report in 2012 projected a 26% increase in RN employment from 2010 to 2020, the largest projected growth of any profession (U.S. Bureau of Labor Statistics, 2012). RN demand is projected to outstrip RN supply. Various studies using different models suggest a range of shortage of 300,000 to 1 million RNs by 2020 (Juraschek et al., 2012) With about 50% of RNs within 20 years of retirement, the RN population will need to grow at a higher rate than it has historically to meet future needs (Juraschek et al., 2012).

A Healthcare System in Transition

Historically, there have been attempts to contain costs in health care, such as the development of Medicare's prospective payment system (PPS) for hospitals using diagnosis-related groups (DRGs), as a basis for reimbursement in the 1980s and capitated reimbursements for hospitals and physicians in the 1990s. This was intended to improve the quality of care while containing costs (Cromwell, Trisolini, Pope, Mitchell, & Greenwald, 2011).

In the Institute of Medicine's (IOM) (2011) report "Crossing the Quality Chasm," a call went out for an increase in payments to providers of high quality care. The current legislative attempt to improve the healthcare system is the Affordable Care Act, which includes new methods of reimbursement under which hospitals will be rewarded for good patient outcomes and receive reduced payments for areas of quality that are not achieved.

The quality of care, not the quantity of care, will be the basis for determining the reimbursement hospitals and physicians will receive. The Hospital Value-Based Purchasing Program is one mechanism that will be implemented to accomplish this change. This pay-for-performance approach to the payment system is intended to allow patients to receive higher quality care, experience better outcomes, and in the long term, reduce healthcare costs (, 2011). The dialysis community is not exempt from these changes in payment methodology. The ESRD program has also been moved to a pay-for-performance method of reimbursement from Medicare. This includes shifting from the previous "composite rate" solely to the "bundling" of costs. Under the bundle, providers are paid one amount per person per treatment for all dialysis, erythropoietin (EPO), vitamin D, intravenous (IV) iron, all ESRD laboratory tests, and oral medications with IV equivalents. The base payment was calculated, and adjusters were put in place for outliers, such as low volume, geographic location, and high-cost outliers. Home therapies will be funded at an equal level with in-center treatments (Charytan, 2010).

In addition to the bundled costs, a Quality Incentive Program (QIP) was instituted to reflect a pay-for-performance method of reimbursement for dialysis providers. Implementation of this transition is scheduled to take place over a four-year period, with quality indicators being adjusted each year. The first QIP indicators under which programs were evaluated were anemia management and dialysis adequacy. For the performance year 2012, QIP was expanded to include three clinical measures (anemia management, hemodialysis adequacy, and type of vascular access) and three reporting measures (dialysis safety events [including infection rates] patient satisfaction, and mineral metabolism monitoring) (Fishbane & Hazzan, 2012). Another indicator relevant to the dialysis world is the hospital monitoring of central line-associated bloodstream infections (CLABSIs). Hospital-based dialysis units and acute programs will be evaluated on this important infection control issue (Centers for Medicare and Medicaid Services [CMS], 2012).

Nurses Are at the Front Lines Of Managing Quality

The standards governing dialysis programs under the pay-for-performance mandate are important and challenging. Nurses are vital to the success of the unit or program reaching specific goals. An IOM (2001) report suggested modifications that must be made in the way healthcare professionals are regulated and accredited to facilitate the needed changes in care delivery. The dialysis community is responding to that suggestion.

CMS has implemented regulations that require mandatory certification for dialysis technicians within 18 months of employment (CMS, 2008). The revisions of the ESRD Interpretive Guidance in 2008 stated that these regulations were "... in the interest of health and safety of individuals who are furnished services" (CMS, 2008, Subpart A, 494.1). In outpatient hemodialysis facilities, technicians provide the majority of chair/bedside care for patients undergoing treatment. Nurses supervise the technicians and provide oversight and management for the unit; however, certification for the nursing staff employed in dialysis units remains voluntary.

Certification is defined by the American Board of Nursing Specialties (ABNS) as "the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes" (Niebuhr & Biel, 2007, p. 176). Nurses who choose to become certified provide the public with the assurance of their expert knowledge and clinical judgment based on current industry standards and procedures (American Association of Critical Care Nurses [AACN] & the AACN Certification Corporation, 2003).

With the challenges of ever-increasing complexity in technology, equipment, cultural impacts, and changes in reimbursement that are facing nephrology in the current environment of healthcare change, nurses with specialty certification can make a difference in patient outcomes by bringing advanced knowledge, skill, and expertise to care for these patients who are older and sicker with more co-morbid conditions (Valente, 2010).

Demonstrated Effects Of Certification

Certified nurses demonstrate a higher level of confidence in decision-making and self-assurance in recognizing and attending to patient needs (Kaplow, 2011). In nephrology, they can analyze data appropriately to fill the need for anemia and mineral bone management. As educators, certified nurses can increase patients' understanding of the importance of adherence with their treatment plan to enhance dialysis adequacy, and they can collaborate with the healthcare team to facilitate early access placement. Nurses maintain close relationships with their patients; thus, they can be effective in overcoming patient-specific barriers in their treatment plan. Nurses report increased feelings of empowerment, self-confidence, and self-esteem with certification (Kaplow, 2011; Piazza, Donahue, Dykes, Griffin, & Fitzpatrick, 2006; Redd & Alexander, 1997; Twibell et al., 2008), which should enable them to collaborate more effectively with members of the healthcare team to foster individualized patient plans of care.

Low infection rates, especially preventing CLABSIs, are essential in promoting a healthy patient population. A hospital-based study found that having an infection control director certified in infection control was a significant independent predictor of lower methicillin resistant staphylococcus aureus (MRSA) bloodstream infection (BSI) rates (Pogorzelska, Stone, & Larson, 2012). In a study of intravenous (IV) insertions, specialty certified nurses performed 20% higher than non-certified nurses in terms of duration, difficulty, site, and type of procedure (Ericsson, Whyte, & Ward, 2007). Other studies have demonstrated higher success rates and more positive outcomes related to certified specialty nurses in the areas of wound care and pressure ulcers (Hart, Bergquist, Gajewski, & Dunton, 2005), lower fall rates (Kendall-Gallagher & Blegen, 2009; Lange et al., 2009), and equal outcomes of certified nurse anesthetists compared to physicians (Simonson, Ahem, & Hendryx, 2007). An important study by Blegen (2012) revealed that hospitals with a larger percentage of nurses who had baccalaureate degrees and certification also had lower 30-day mortality and failure to rescue rates for surgical patients. These elements show a direct correlation between certified nursing care and positive patient outcomes.

Demonstrated Effects On Nurse Satisfaction

Nurse satisfaction plays a significant role in affecting patient outcomes. An Italian study looked at patient satisfaction with the quality of their dialysis care. The findings of this study indicated that "information" was the most critical dimension of the patient's relationship with the nursing staff. The study also showed a significant positive correlation between staff personal accomplishment ratings and client satisfaction. There was a significant negative correlation between staff emotional exhaustion and patient satisfaction (Argentero, Dell'Olivo, & Ferretti, 2008). Certified nephrology nurses report high levels of enhanced feelings of personal accomplishment, personal satisfaction, and professional growth, in addition to validation of their specialized knowledge (Prowant, Niebuhr, & Biel, 2007).

Because nurse satisfaction affects patient outcomes, the financial stability of a healthcare organization, including a dialysis clinic, is affected. A 2007 study of hemodialysis facility staff found that nurses' perceptions of their work environment were significantly related to a nurse's intention to leave his or her job, nurse turnover in dialysis facilities, and patient hospitalizations (Gardner, Thomas-Hawkins, Fogg, & Latham, 2007).

Demonstrated Effects On Patient Satisfaction

Patients report higher levels of satisfaction when cared for by a certified nurse (Stromberg et al., 2005). These ratings may be attributed to reports of a decreased incidence of patient care errors and complications, and better patient outcomes (Kaplow, 2011). In a 2007 study by Craven, a hospital unit developed a certification initiative in response to a perceived need to improve patient outcomes. In one year, the number of certified nurses increased 600/0, the RN turnover rate decreased from 16.7% to 8.1%, and the RN vacancy rate decreased from 11.0% to 4.7%. At the beginning of the certification initiative, 88.2% of patients rated their overall satisfaction with nursing care as "excellent." At the end of the year, the unit's "excellent" responses had increased to 90.4%.

The Magnet Recognition Program--Can It Be a Model?

The Magnet Recognition Program[R], developed by the American Nurses' Credentialing Center (ANCC), an organizational component of the American Nurses Association (ANA), has become a standard for best practices in hospitals across the country (Kelly, McHugh, & Aiken, 2011). In 2011, ANCC announced a new model for the Magnet program that grouped the 14 Forces of Magnetism into five key components: transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvement, and empirical quality results (ANCC, 2012). Nursing certification is increasingly important to the attainment of Magnet status, reflecting a more highly educated nurse workforce and a nursing structure that promotes the growth and development of nurses (Ingle, 2004).

Over time, Magnet status has earned a reputation for good patient and nurse outcomes (Aiken, Clarke, & Sloane, 2002). Earning Magnet status yields public recognition for high levels of nursing care excellence, positive work environments, improved patient outcomes, greater collaboration among nurses and physicians, and safer work environments. Hospitals that have earned Magnet Recognition Program status report higher nurse satisfaction based on research surrounding their work environments (Kelly et al., 2011).

While not all hospitals achieve Magnet status, many still strive to emulate the core values of that program. No similar program for evaluating dialysis clinics exists, although hospital-based dialysis programs are included in the hospital's Magnet process. However, some studies reflected core Magnet values and the standards these values promote that evaluated the work environment in dialysis facilities. Results from two studies of nephrology nurses that address nephrology nurses' perceptions of their work environments are shown in Figure 1 (Gardner et al., 2007; Thomas-Hawkins, Denno, Currier, & Wick, 2003). Both studies utilized the Practice Environment Scale of the Nursing Work Index (PES-NWI) to evaluate the key domains of nursing that reflect Magnet attributes. Subscale mean scores above 2.5 represent agreement that the subscale characteristic is present in the work environment. These data show improvement in all areas of dialysis nurses' perceptions of the attributes of their work environments over a four-year period. The report on an ABNS study in 2007 addressing the perceived value of certification revealed that challenges still remained in the areas of appropriate recognition, incentives, and rewards for certification (Prowant et al., 2007).

Connecting Certification to Good Business and the Bottom Line

Retention of nurses is an important financial marker. Replacement of a nurse can cost a company from 50% to 200% of that nurse's salary at the time of departure (ANA, 2012; Atencio et al., 2003; Jones & Gates, 2007). There are additional direct and indirect costs of turnover. Overtime hours and associated stress are significant on the remaining workforce because of the need to cover required patient care and can lead to increased burnout that increases the intent to leave by the existing staff. Advertising the position, sign-on bonuses, possible relocation or travel costs, time in interviewing, checking references, reorganizing patient or staff schedules, use of per diem or traveling staff, and lost productivity all impact the overall cost of hiring (Atencio et al., 2003; Jones & Gates, 2007; Renal Business Today, 2007).

There is also the cost of orientation and training, which can be lengthy depending on the available candidate pool and its base of knowledge and experience. Replacement nurses can bring new ideas and creativity to the workplace, but turnover causes a loss of organizational knowledge that is important in unit stability.

Other costs are related to patient outcomes. Turnover causes staff shortages that are associated with significant decreases in the general quality of patient care and increased length of patient hospital stays (Hunt, 2009). Decreased nursing hours have been shown to increase complications, hospitalizations, and failure to rescue (Atencio et al., 2003).

Burnout and dissatisfaction predict nurses' intentions to leave their current jobs (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Nurses have reported negative interactions with managers, staffing levels, and inadequate supplies to do their job as areas of concern that affected their intent to leave their current position. In another study, poor management and a lack of flexibility in the work schedule were among nurses' top complaints (Brewer, Kovner, Yingrengreung, & Dujik, 2012). On the other hand, nurses who are empowered to do their jobs and who are recognized for their expertise may be more likely to remain in the organization (Piazza et al., 2006).

Managers need training and support in making personnel decisions to build the strongest organization that supports nurse retention and minimizes the costs of turnover and recruitment. While some turnover may be appropriate to eliminate staff members who do not fit the model of the organization or whose skills are not adequate, it is more effective and less costly to refine recruitment and hiring practices to screen for persons more closely aligned with company values. Questioning prospective employees about their desire to learn and grow professionally will lead toward staff who are certified or who are interested in becoming certified a cost-effective investment required for orientation and training.

An ABNS study reported that 86% of the nurses responding to a survey indicated that with all other elements being equal, they would hire a certified nurse over a non-certified nurse (Stromberg et al., 2005). Reasons for this choice included the proven knowledge base in their specialty yielding increased expertise; demonstration of a life-long commitment to learning indicating motivation, professionalism, and commitment to their career; and documented experience in the chosen specialty. These nurse managers were also more likely to assign a patient with complex problems to a certified nurse (Stromberg et al., 2005).

Retention of certified nurses is essential in these turbulent times of transition in the healthcare reimbursement arena. This should be most apparent to nurse managers in the nephrology community. In the 2007 survey by Prowant and colleagues, nurse managers responded more positively than other nurses to the concepts that certification promotes recognition by other health professionals and enhances professional autonomy (Prowant et al., 2007). Certified nurses report a sense of empowerment, which leads to increased job satisfaction and an increase in retention (Haskins, Hnatiuk, & Yoder, 2011; Kaplow, 2011; Piazza, et al., 2006).

Salaries for certified nurses nationally are higher than non-certified nurses, although there are no dialysis-specific data available for direct comparison. A survey in 2006 reported that those who were certified in a specialty made $9,200 more annually than nurses who were not certified (Mee, 2007). It was also reported that reimbursement for certification fees increased by 10% in 2011 (Nursing 2011, 2011).

A salary comparison by Advance for Nurses in 2011 does not specify nephrology as a category, but it showed higher salaries for certified nurses compared to their non-certified colleagues in the majority of categories and locations (Keefe, 2011).

The cost-benefit analysis of these salary changes needs to be tied to the development of a method to determine the economic value of nursing by considering the costs of hiring certified registered nurses as they relate to the gains in quality patient care and patient satisfaction resulting from their employment (Jones & Gates, 2007). This has not been studied in the nephrology setting, leaving an area in need of more research.

During the recession, many older nurses have stayed in the workforce, increased their hours on the job, or returned to the workforce due to financial constraints (Brewer et al., 2012; Pecci, 2012). New graduate nurses who have had difficulty finding positions are biding their time and preparing to make a move as the financial situation changes and positions begin to open up (Brewer et al., 2012; Pecci, 2012). The nursing shortage improved around 2008, but the numbers are again starting to trend upward, bringing a resurgence of higher vacancy and turnover rates as the recession eases and Baby Boomer nurses start to decrease their hours or finally retire. This will provide more opportunities for younger nurses.

Employers who cared for their nursing staff will be in the best positions to avoid a surge in vacancies. Retention strategies must be maintained throughout the recession to ensure adequate nursing staff availability for the future and to prevent a negative impact on the company's bottom line (Brewer et al., 2012; Pecci, 2012).


Many factors affect a company's bottom line, including changes in reimbursement practices, demands for improved outcomes, retirement of Baby Boomers, and the influx of patients with kidney disease, to name a few. The need for health care is increasing and becoming more challenging to deliver in a cost-effective manner. The increased need coupled with increased challenges demand that the value of certified nurses be critically evaluated for the perceived benefit they may add to the financial equation.

Strong nursing care can improve the quality of care provided by an institution, which benefits the patient population being served, as well as the economic status of the organization. A culture of excellence begins with the power of knowledge. Nurses who have sought certification have demonstrated a desire for excellence for themselves and their healthcare community. In addition, certified nurses may be less likely than non-certified nurses to change employment as they experience improved work environment and increased job satisfaction. Certified nurses are key to the quality of care the current transitioning healthcare system demands, yielding a positive impact on the bottom line of the business that employs and retains them.


To provide an overview of the benefits specialty nursing certification has on patient care, nursing job satisfaction, and return on investment.


1. Discuss upcoming changes and challenges in the U.S. healthcare system.

2. Describe the benefits of nursing certification to business.

This offering for 1.4 contact hours is provided by the American Nephrology Nurses' Association (ANNA).

American Nephrology Nurses' Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CFP 00910.

This CNE article meets the Nephrology Nursing Certification Commission's (NNCC's) continuing nursing education requirements for certification and recertification.


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Helen F. Williams, MSN, RN, CNN, is Former Secretary, Chairperson of CDN Test Committee, and Recertification Chairperson, and Current Commissioner, NNCC; Assistant to the Manager, Special Projects, Denver Acute Dialysis Team, Fresenius Medical Care, Denver, CO; and a member of ANNA's High Country Chapter. She may be contacted directly via e-mail at

Greg Lopez, BSN, RN, CNN, was a NNCC Commissioner from 2009-2013 serving on the CDN Test Committee (2009-2071); Commissioner from 2010-2013 serving on the CNN Test Committee (2011-2013); is NNCC Treasurer; is the Quality Manager, Fresenius NA, New Orleans, LA; and a member of ANNA's Fleur de Lis Chapter.

Kathryn Lewis, MSN, RN, is Clinic Manager, Fresenius NA, New Orleans, LA; and a member of ANNA's Fleur de Lis Chapter.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 254.

Figure 1
Comparison of Survey Results, 2003 and 2007

Subscale Mean Score

                  2003   2007

in dialysis       2.25   2.87

foundations       2.73   3.26
for quality of

Staffing and
resource          2.28   2.80

leadership,       2.82   3.28
and support
of nurses

nurse-physician   2.90   3.22

Sources: Gardner et al., 2007; Thomas-Hawkins et al., 2003.

Note: Table made from bar graph.
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Title Annotation:Continuing Nursing Education
Author:Williams, Helen E.; Lopez, Greg; Lewis, Kathryn
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:May 1, 2013
Previous Article:Nephrology certification: what is it?
Next Article:Fifteen-minute versus thirty-minute blood pressure evaluation during chronic hemodialysis.

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