Debra R. Hanna¹

¹ Professor Division of Nursing Molloy College, Estados Unidos.
dhanna@molloy.edu

Recibido: 16 de noviembre de 2015 / Enviado a pares: 20 de noviembre de 2015 / Aceptado por pares: 14 de enero de 2016 / Aprobado: 20 de enero de 2016

10.5294/aqui.2016.16.1.2

Para citar este artículo / To reference this article / Para citar este artigo

Hanna, DR. A Proposal for Certification in Nursing Theory. Aquichan. 2016; 16 (1): 7-14. DOI: 10.5294/aqui.2016.16.1.2

The author proposes the development of different levels of certification in the knowledge of nursing theory that would be based on the level of formal education attained. At present, nurses are being required to obtain higher levels of formal education in order to serve patients safely in a technologically complex health care system. Although evidence-based practice is strongly desired in contemporary health care, less consideration has been given to the value of theory-based nursing practice or the relationship between theory and research. The author explains multiple background issues and then highlights several questions that are important for disciplinary discussion at this point in time.

KEYWORDS

Nursing theory; theory-based practice; certification (Source: DeCS, BIREME).

El autor propone el desarrollo de diferentes niveles de certificación en el conocimiento de la teoría de enfermería que se basan en el nivel de educación formal alcanzado. En la actualidad, se está exigiendo que las enfermeras obtengan niveles más altos de educación formal con el fin de atender a los pacientes de forma segura en un sistema de atención de la salud tecnológicamente compleja. A pesar de que la práctica basada en la evidencia es muy deseable en el cuidado de la salud contemporánea, menos atención se ha prestado al valor de la práctica de enfermería basada en la teoría o a la relación entre la teoría y la investigación. El autor explica los múltiples problemas de fondo y luego se ponen de relieve varias preguntas que son importantes para la discusión disciplinar en este momento en el tiempo.

PALABRAS CLAVE

Teoría de enfermería; la práctica basada en la teoría; certificación (Fuente: DeCS, BIREME).

O autor propõe o desenvolvimento de diferentes níveis de certificação no conhecimento da teoria de enfermagem que se baseiam no nível de educação formal atingido. Na atualidade, exige-se que as enfermeiras obtenham níveis mais altos de educação formal a fim de atender os pacientes de forma segura num sistema de atenção da saúde tecnologicamente complexa. Embora a prática baseada em evidência seja muito desejada no cuidado da saúde contemporânea, pouca atenção tem sido prestada ao valor da prática de enfermagem baseada na teoria ou na relação entre a teoria e a pesquisa. O autor explica os múltiplos problemas de fundo e, em seguida, destaca vários questionamentos que são importantes para a discussão disciplinar neste momento.

PALAVRAS-CHAVE

Teoria de enfermagem; prática baseada na teoria; certificação (Fonte: DeCS, BIREME).

In 2010, nurses received a 'call' in the United States of America (USA) in the form of "The Future of Nursing," (1) a document issued by the Institute of Medicine (IOM) to increase the levels of formal education of nurses in general and to put more highly educated nurses into the health care workforce. According to its website, the Institute of Medicine is a division of the National Academies of Sciences, Engineering and Medicine. The academies are private, non-profit institutions that provide independent, objective analysis and advice to the nation [United States of America] and inform public policy decisions related to science, technology, and medicine. (http://iom.nationalaacademies.org/About-IOM.aspx)

"The Future of Nursing" report was requested by a private foundation, the Robert Wood Johnson Foundation (RWJF), and was jointly sponsored by RWJF and the IOM. Since the intent of IOM- sponsored documents is to inform public policy decisions, this report has already influenced many policies and public laws affecting nursing in the United States.

Shortly before "The Future of Nursing" report was issued, another document called the "LACE Initiative" was released in 2008 by the Advanced Practice Registered Nurse Joint Dialogue Group (2). LACE is an acronym that stands for the formal document called: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. By addressing licensing, accreditation, certification, and education in one document, nursing was provided with a model to show how these elements are all related to the knowledge needed for advanced practice nursing. This same model can now be considered for four different levels of nursing practice. By doing so, the relationship of theory to practice and of theory to research, as well as the standards for teaching theory at these different levels of education can be made clear.

In the five years since the IOM report was issued, nursing has continually built upon its existing educational structure, which traditionally included basic nursing education that led to the first RN license, graduate nursing education that could lead to advanced practice or other leadership roles, and doctoral nursing education. For the purpose of this discussion about certification in nursing theory, I would like to address four clearly defined levels of nursing practice in the United States that each requires a different depth and breadth of nursing knowledge. The different types of knowledge needed by nurses with different levels of education are not only related to the work they will do, but also to how they will use the nursing knowledge they need for different nursing roles.

I contend there are four distinct levels of nursing practice that are based on four different levels of education. The purpose for each level of education affects the type, breadth and depth of content taught at each level. The first level is generalist practice, which requires basic education for registered nurses that leads to the first nursing license. At this level, student nurses are expected to use nursing knowledge to think critically, carefully, and in a way that protects patient safety. The definition of nursing as has been advanced by the American Nurses Association should be able to be upheld by a nurse who has attained this first, basic level of education. The second level of education is advanced practice, which requires graduate education that can lead to an advanced practice certification or an advanced practice license. The third level of nursing practice is a clinical doctorate, which requires the Doctor of Nursing Practice (DNP) level of education. For the DNP, educational preparation further develops advanced practice clinical leadership and translational research activities. Please note that the DNP degree is not the only clinical doctorate, but to streamline this discussion, only that degree is mentioned here. Finally, the fourth level of nursing practice is the research doctorate, at the PhD doctoral level of education. The PhD level of education leads to knowledge generation activities, such as primary research.

To provide the public with some indication that the competency needed for each level of practice has been attained, credentials must be obtained by a particular nurse. The credentials for safe generalist practice usually include graduation from an accredited school/program and a test for basic licensure. The credentials for safe advanced practice usually include graduation from an accredited school/program and either taking a test for advanced practice certification or, in some geographic areas, presenting a portfolio of the applicant's work. At present, the credentials for doctoral advanced practice include those for generalist and advanced practice, and graduation from an accredited DNP (or similar) program. Depending on the geographic location where a research doctorate is earned, the structure of the PhD program can differ. The credentials for a research doctorate can include an earned degree from an accredited school with a PhD program. The value of the PhD degree is related to the quality of the PhD program itself. For nurses with a PhD in nursing, others evaluating the nurse scholar's credentials might want to see additional credentials such as a basic nursing license and earned degrees at the undergraduate and graduate level of education; they might also request credentials for advanced practice.

When considering these different levels of education and practice, and the factor of patient safety, which credentialing is meant to protect, the abilities of individual nurses to evaluate, use, and develop nursing knowledge now have greater importance. It seems the time has come for the nursing discipline to consider formal certification of theoretical nursing knowledge at each of those levels.

When Carper (3) described four fundamental patterns of knowing in nursing, she categorized types of knowledge, such as empirical, aesthetic, personal, and ethical. Carper's work was essential to advance the development of nursing knowledge, since it helped nurse scholars engage in discussion about the many types of knowledge needed. Since 1978, additional patterns of knowing, such as socio-political knowledge (4) or evidence-based knowledge (5), have been added to Carper's original four patterns. As it was not part of Carper's original research question, Carper's paper did not address the depth or the breadth of nursing knowledge at that time. However, Carper's work from the 1970s remains foundational to nursing knowledge today and it is partly because of her work then that today's nurse scholars can now discuss the depth and breadth of knowledge that certification is meant to address.

Donaldson and Crowley's 1978 paper entitled "The Discipline of Nursing" (6) helped nurse scholars to classify the two sides of our disciplinary knowledge: the professional practice side and the academic side. The professional practice side of knowledge addresses the clinical knowledge nurses need to practice their profession. The academic side of knowledge is the theoretical knowledge that professors use when teaching disciplinary content to students of nursing. Since 1978, many other scholars' insights that were inspired by Donaldson and Crowley's paper have helped us to consider our nursing knowledge more carefully.

The most important nurse scholar who addressed all aspects of credentialing in nursing, including the certification of nursing knowledge, was Margaretta Styles (7). Styles' work began in the United States, and it evolved to achieve international scope when she led the International Council of Nurses. Nurse scholars began to understand the relationship between credentialing the schools where nurses are educated (accreditation of educational institutions) and credentialing individual nurses through proper educational preparation, licensure, and certification. Whenever different kinds of credentialing were debated throughout the 1980s, 90s, and early 2000s, new questions arose and insights emerged. The essential elements that Styles helped us to understand were that credentialing exists to protect patient safety, that there is a mutually reinforcing relationship among the different types of credentials, and that each credential has its own scope and standards. Accreditation of educational programs is related to the scope of education. (7, p. 30) Licensure for generalist or basic practice is earned by an individual nurse when minimal competency to practice safely in the discipline can be demonstrated through educational preparation in an accredited program and through a licensing exam. The licensing exam is the credential for the individual nurse's scope of practice. (7, p. 30) The credentials earned at the basic level do not guarantee the individual nurse will never make a mistake. Rather, the credentialing process is meant to show that certain standards have been upheld throughout the educational and licensing processes.

What often happened after a nurse completed basic education and received the privilege of a license to work was that many nurses developed specialty-based knowledge in one particular area of professional nursing. Determining who could be called a 'specialist' in a particular type of nursing resulted in more discussion. Certification was another credential that was developed to demonstrate to the public that the certified nurse had achieved competency in a particular specialty area within the discipline of nursing. However, certification, such as the test for a basic nursing license, demanded certain standards and required formal testing that was meaningful for the credential being provided. According to Styles' model, certification is meant to testify to the individual nurse's scope of expertise. (7, p. 30) Since expertise is often related to on-going development of knowledge in a specialty, this credential is often given for limited periods of time. Its renewal depends on the individual's ability to show that certain standards have been maintained.

Another point that came into this particular discussion of specialty-based practice, advanced practice roles, and credentialing was where graduate education should or must fit. In the 1980s, there were some nurses who would call themselves advanced practice nurses who did not have proper education or credentials. However, at that point in time, the standards for credentialing were not well-delineated for all advanced practice roles. (7) This part of the discussion involved a concept called 'title protection,' which meant that only people who have obtained the proper credentials may call themselves by a particular title. The discussions that occurred during the 1980s, 90s, and early 2000s helped to develop credentialing standards at the advanced practice registered nurse level (APRN). In 2008, a major milestone was achieved when the "LACE initiative" was formally approved in the USA. The LACE initiative was developed by a panel of representatives from many specialty nursing organizations, but was possible because of Styles' scholarly work to delineate individual and institutional credentials.

Although so much has already been accomplished with credentialing in nursing, there is still more to discuss about the depth and breadth of our nursing knowledge and about the ability of nurses to evaluate, use, and develop nursing knowledge, especially in relation to the levels of academic preparation that nurses need today. A particular need is related to theoretical nursing knowledge, how it is taught at each level of education, and how it is used at each level of practice.

The "2010 Future of Nursing" document was not about types of knowledge like Carper said. It was not about the two sides of knowledge like Donaldson and Crowley said. It was not about the types of credentialing that Styles worked so hard to develop. Rather, the "2010 Future of Nursing" report was more clearly aimed at the depth and breadth of nursing knowledge needed at each level of practice so that formal nursing education could reach its full potential in nurses' work. At the 2015 Roy Adaptation Association-International Conference held at Boston College, an international group of nurse scholars discussed how we might help others learn the true value of theory-based nursing practice. The idea of certification for nursing theory, especially for certification in using the Roy Adaptation Model, was discussed briefly. It seemed that by discussing the certification of a nurse's theoretical knowledge, nurse scholars might develop ways to affirm the depth and breadth of knowledge that nurses need at each level of practice.

After the conference ended, I was still thinking about that idea. I reflected on my own personal journey as a nurse. It occurred to me that the level of theoretical knowledge staff nurses need is different from the level of theoretical knowledge that advanced practice nurses need. Likewise, nurses with DNP degrees and with PhD degrees would use theoretical knowledge in different ways for the different kinds of scholarly work they each do.

In 1988-90, when I was a graduate student, I had the privilege of working with Dr. Keville Frederickson on her research project called "Linkages in Nursing Excellence." While working under Dr. Frederickson's direction, I taught staff nurses about the Roy Adaptation Model (RAM) to help them understand how the four modes, three levels of stimuli, and two coping processes of the RAM could be used to nurse patients in a neuroscience nursing unit. Later, when I became a credentialed clinical nurse specialist, I used middle range theories in combination with the RAM conceptual model for very complex clinical cases. Using multiple theories or combining a conceptual model with middle range theories should happen with ease for advanced practice registered nurses. There should be some facility with using, evaluating and even developing theory-based as well as evidence-based knowledge at that advanced practice level of nursing. Currently, the emphasis is on developing evidence-based knowledge as if evidence and theory are opponents. However, if the proposal to use the term "theory-based evidence" were supported more widely, then the blending of theory and evidence in practice would enrich the quality of patient care provided (8).

Later, in my own career, when I was in doctoral studies, the underlying philosophical assumptions of the Roy Adaptation Model became so much more important to me. Perhaps understanding philosophical assumptions is the depth of knowledge needed at the PhD level to influence policy-making or to conduct research with insight and understanding. Doctoral education at the PhD level helps to hone analysis and interpretation skills, so it seems necessary that the PhD level of education would be where the grasp of theoretical knowledge would require the greatest depth and breadth.

My understanding of a DNP degree is that nurses with this education will direct their scholarly work toward translational research. Working with other disciplines to develop the theory-based evidence for nursing practice would require firm grounding in a nursing approach to theoretical knowledge that differs from the use of theoretical knowledge made by team members from other disciplines, even when the same theoretical constructs are used by team members. For example, wouldn't nurses who are grounded in the Roy Adaptation Model use a different theoretical approach to patients and families under stress than other members of the team, such as physicians and social workers? Whereas RAM nurses would seek to examine the adaptation level outcomes and the coping processes, physicians and social workers might focus on other aspects of patient and familial stress. It is mainly because each professional offers a different disciplinary perspective to that team's collaborative effort on behalf of the patient that outcomes of care are strengthened.

These reflections on the stages of my own professional journey led me to a series of questions that might be discussed in our discipline. The questions listed here are not the only ones, but they are listed as a way to start disciplinary discussion. First question: Would it be worthwhile to establish a structure for certification of theoretical nursing knowledge at four levels: Basic Practice (BS); Advanced Practice (MS); Translational Practice (DNP); and Knowledge Generation Practice (PhD)? If certification of individual nurses is aimed at the scope of expertise, should expertise in theory be developed at each level so that the expectations for use, evaluation, and development of nursing knowledge are clear? Second question: If we define the relationship between theory and practice at each level of education, how should the teaching of theory be differentiated at each level so that each level of education builds upon the other levels? What standards for teaching might be developed to ensure theory is taught in a useful, practical way? Third Question: Could the discipline of nursing develop standards to determine who would be certified or not? If so, at which levels would nurses be certified in theoretical nursing knowledge? Fourth question: Which criteria would be best suited to determine the scope of expertise in theoretical nursing knowledge for each level? Where we have cultural assumptions acting in certain cultures, how will the certification criteria accommodate those differences? Could we use something like a portfolio format for awarding different levels of certification? Could we provide a test at a very basic level, another test at the APRN level, and after passing those, something like a portfolio of the applicant's work related to the model, such as a completed theory-based research project? Fifth question: For the DNP level, would a capstone translational research project such as the process outlined in Roy's book (9) Generating Middle Range Theories be sufficient to award certification at that level? For the PhD level, perhaps the publication of a primary theory-based research study would be needed. A final question that needs discussion is: Would certification in nursing theory be something that would be achieved once and kept for life or is it something that would require periodic updates?

These questions, prompted by our discussion at the 2015 Roy Adaptation Association International Conference, need discussion in our discipline. For years, nurses have been obtaining higher levels of formal education and have been contributing to the development of nursing knowledge. Here is a chance to elevate the status of our theoretical nursing knowledge by developing clear criteria for teaching, learning, and using the theoretical knowledge needed for each level of practice. If the "2010 Future of Nursing" report issued a 'call' for nurses to be able to work to the full level of their education, let us now respond by saying it is time to certify nurses for the depth and breadth of theoretical knowledge needed at each level of nursing.

Declaration

The author declares no conflict of interest with the journal. The author declares this manuscript represents the original thinking and writing of the author. This manuscript has not been offered to any other journal for consideration.

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