Certification, Empowerment, and Intent to Leave Current Position and the Profession Among Critical...

CERTIFICATION,EMPOWERMENT, ANDINTENT TO LEAVE CURRENTPOSITION AND THEPROFESSION AMONGCRITICAL CARE NURSESBy Joyce J. Fitzpatrick, RN, MBA, PhD, Theresa M. Campo, RN, DNP, NP-C,Gregory Graham, MA, and Ramón Lavandero, RN, MA, MSN

Background This study was based on the American Associationof Critical-Care Nurses’ (AACNs’) interest in determining thevalue and influence of specialty certification.Objectives To examine relationships between AACN specialtycertification and empowerment, and, secondarily, to examinethese variables as related to intent to leave the current positionand the nursing profession.Methods AACN members were asked to participate in a Web-based survey; 6589 AACN members completed the surveys.Results Perceptions of empowerment differed significantlyamong nurses certified by AACN and nurses without suchcertification. Additional analyses revealed significant differencesin empowerment related to position, education, salary, ethnicity,sex, intent to leave the current position, and intent to leavethe profession. Forty-one percent of the participants indicatedintent to leave their current position in the next year; only 6.9%indicated their intent to leave the profession in the next year.Intent to leave current position differed significantly accordingto age, sex, years of experience, ethnicity, educational level, andcertification.Conclusions The value of specialty certification and the impor-tance of empowerment among critical care nurses are affirmed.The next step in the continued journey toward increasing reten-tion of critical care nurses, and thereby improving patient care,is to evaluate existing programs focused on retention andidentify needed enhancements. (American Journal of CriticalCare. 2010;19:218-229)©2010 American Association of Critical-Care Nurses

doi: 10.4037/ajcc2010442

Challenges in the Critical Care Workplace

C E 1.25 Hours

Notice to CE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understanding ofthe following objectives:

1. Determine the relationship between AACNspecialty certification and empowerment.

2. Identify the relationship between certification,empowerment, and intent to leave currentposition and the profession.

3. Evaluate the value of AACN specialty certifi-cation and retention of staff.

To read this article and take the CE test online,visit www.ajcconline.org and click “CE ArticlesinThis Issue.” No CE test fee for AACN members.

E RBEvidence-Based Review on pp 228-229

218 AJCC�AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3 www.ajcconline.org

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According to the AACN Certification Corpora-tion, certification is a process by which a non-governmental agency validates, on the basis ofpredetermined standards, an individual nurse’squalification for and knowledge of practice in adefined functional or clinical area of nursing. AACNcertification validates a nurse’s knowledge in thespecialty area of critical care nursing; certification isseen as adding personal value by recognizing thenurse’s competencies. Several types of critical carecertification are offered through AACN. Each ofthese requires a specified number of clinical hoursof direct patient care and successful completion of acertification examination.1

BackgroundThe value of specialty certification has not been

examined extensively in research. Yet considerableinterest has been expressed in the relationshipbetween certification, nurses’ perceptions of theirwork life, and nurses’ subsequent retention.2 Thistopic is especially relevant because nurse retentionis a key strategy in addressing the nursing shortage,and retention of critical care nurses is of particularinterest to hospitals. Critical care nurses are highlyskilled and often difficult and costly to replace.

Of particular interest to the present study arestudies relating the variables of nurses’ perceptionsof empowerment and certification to their intent toleave their current position or the nursing profession.Although previous research has linked 2 of these vari-ables (empowerment and certification), no previous

research has linked all 3 of the variables among anational sample of specialty-certified nurses. In thisstudy we were interested in the intent-to-leave vari-ables as a way of indirectly assessing potentialretention of critical care nurses.

Kanter’s theory of structural power in organiza-tions, which postulates that employees who haveaccess to empowerment structures have greater workeffectiveness, has formed the basisfor much of the nursing research onempowerment.3 The theory of struc-tural empowerment is organizedwith the following constructs: (1)opportunity structures, defined asopportunities for growth, learning,and movement within the organiza-tion, and (2) power structures,including information, resources,and support. Formal and informal power are neces-sary to access these structures. According to the the-ory, successful members of organizations are thosewho feel empowered and experience increasedautonomy, decreased job stress, lower burnout,increased job satisfaction, and higher commitment.3

Much of the empowerment literature in nursingis based on the work of Laschinger and colleagues.Laschinger4 has applied Kanter’s theoretical modelof power within organizations to an understandingof nurses’ work environments. In the studies byLaschinger and colleagues, structuralempowerment has been linked toseveral organizational outcomes,including job stress, job satisfaction,organizational commitment, andpatient satisfaction.5-7 Laschinger alsohas joined with colleagues in testingthe Nursing Worklife Model, whichlinks organizational variables to jobsatisfaction and burnout in nurses.8,9

The present study was designedto extend the work of Piazza and col-leagues,10 who found differences inempowerment between nationally cer-tified nurses and nurses who were not certified. Thatsmall study among nurses employed in a community

The study reported here was initiated by the American Association of Critical-CareNurses (AACN) and funded by the AACN Certification Corporation. It was a directresult of AACN’s continued interest in determining the value and influence of certifi-cation. Also, AACN had the explicit goal of increasing knowledge about certificationfrom the perspective of the organizations in which critical care nurses are employed.

About the AuthorsJoyce J. Fitzpatrick is Elizabeth Brooks Ford Professor ofNursing and Gregory Graham is a lecturer at FrancesPayne Bolton School of Nursing, Case Western ReserveUniversity, Cleveland, Ohio. Theresa M. Campo is a nursepractitioner for Bayfront Emergency Physicians at ShoreMemorial Hospital–Emergency Department, in SomersPoint, New Jersey. Ramón Lavandero is director of com-munications and strategic alliances at the American Asso-ciation of Critical-Care Nurses in Aliso Viejo, California.

Corresponding author: Joyce J. Fitzpatrick, RN, MBA, PhD,

FAAN, Frances Payne Bolton School of Nursing, CaseWestern Reserve University, 10900 Euclid Avenue,Cleveland, OH 44106-4904 (e-mail: [email protected]).

The value of specialty certification hasnot been examinedextensively.

The relationshipbetween certifica-tion, nurses’ perceptions oftheir work life, and nurses’ retention isa focus of interest.

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3 219

Fitzpatrick5_10pgs.qxp:218_227_Fitzpatrick5_10 4/8/10 11:12 AM 19

nurses, particularly in relation to the dependentvariables of empowerment and intent to leave. Itwas expected that both perceptions of structuralempowerment and intent to leave would differbetween critical care nurses with AACN certificationand those without AACN certification. The specificresearch questions were as follows: Are there differ-ences in perceptions of structural empowermentbetween AACN-certified nurses and those who arenot AACN certified? Are there differences in intentto leave (current position and the nursing profes-sion) between AACN-certified nurses and thosewho are not AACN certified?

Methods Sample

A total of 44143 AACN members (those whohad e-mail addresses on file) were contacted by e-mail and invited to participate in a Web-basedsurvey. The link to the survey was kept open on theAACN Web site for 4 weeks, at which time it wasdetermined that, according to a power analysis, thenumber of responses was sufficient to answer theresearch questions. The total sample of respondentsincluded 6589 nurses, a 15% response rate. Addi-tional analyses were conducted among staff nurses;this subsample of staff nurses consisted of 4268respondents. Results related to the staff nurse samplewill be reported in a separate article.

Variables and MeasuresThe Conditions of Work Effectiveness Question-

naire, Revised (CWEQ-II), developed by Laschingerand colleagues,7 was used to measure nurses’ percep-tions of empowerment. The questionnaire includes19 items used to assess perceptions of access to 6empowerment structures: opportunity, information,support, resources, informal power, and formalpower. Each of these 6 components forms a subscaleon the CWEQ-II instrument. In scoring the CWEQ-II,a 5-point Likert-scale is used, with scores rangingfrom “none” to “a lot” for each item. The questionsare positively worded, and a higher score indicates ahigher level of structural empowerment. Items aresummed and then averaged to obtain a subscale scor-ing range from 1 to 5. A total structural empower-ment score is calculated by summing the mean scoresfor all 6 components. Structural empowerment scoresrange from 6 to 30, with the higher number repre-senting a higher perception of structural empower-ment. Scores ranging from 6 to 13 are described aslow levels of structural empowerment, 14 to 22 asmoderate levels of structural empowerment, and 23to 30 as high levels of structural empowerment.

hospital was the first to demonstrate differencesbetween certified and noncertified nurses on any vari-able related to the organization. Yet in the study byPiazza et al, no effort was made to determine whether

the certified nurses had basic or spe-cialty certification. Also, Piazza andcolleagues did not assess nurses’intent to leave in their study.10 Theintent-to-leave variable was of particu-lar interest in the present study.

In a national study of specialtycertification, Niebuhr and Biel11

found no differences in intent toleave among nurses with specialtycertification and nurses who werenot certified. The study, undertakenby the American Board of NursingSpecialties, included 11427 nurses,75% of whom had specialty certifi-cation. Structural empowerment and

organizational commitment were not assessed;rather, the focus of the study was on the intrinsicand extrinsic value of specialty nursing certification.11

In a national study of the work environments of criti-cal care nurses, Ulrich and colleagues12 reported that48.4% of the nurses in their study indicated intentto leave their position in the next 3 years. Yetalmost 75% of these nurses indicated that theyplanned to leave for another position within nurs-ing and were not leaving the nursing profession.12

Zurmehly and colleagues13 studied the relation-ship between empowerment and intent to leave in asample of 1355 registered nurses in west centralOhio. Certification status was not considered inthat study. The researchers found a significant rela-tionship between empowerment, intent to leave thecurrent position, and intent to leave the profession.

Nurses with higher empowermentscores were less likely to leave eitherthe position or the profession.

In summary, although someresearch has been done relating tosome of the variables of interest inthe present study, no other studyincluded all 3 variables of interest inthe present study: perceptions ofempowerment, specialty certifica-

tion, and intent to leave (position or profession). Inaddition, the other studies of certified nurses havebeen focused on specialty certification generallyacross a range of specialties or on oncology, periop-erative, or public health nurses specifically. Thepresent study is the first national study to examinespecialty certification among certified critical care

No other studyhas examined the

relationshipbetween perceivedempowerment,specialty certifi-cation, and intentto leave (positionor profession).

A total of 6589 critical care

nurses respondedto a Web-based

survey.



Cronbach reliability coefficients (α) of 0.93 for theCWEQ-II total score and subscale reliabilities from0.70 to 0.89 have been reported.7 In the presentstudy, the Cronbach alpha for the CWEQ-II totalscore was 0.91. The alpha levels for the subscaleswere as follows: opportunity, 0.86; information,0.91; support, 0.90; resources, 0.78; formal power(Job Activity Scale), 0.80; and informal power(Organizational Relationship Scale), 0.75.

National certification status was determinedfrom participants’ self-reports. Participants were askedabout specialty certification through AACN and othernational organizations. A checklist of all of the AACNcertifications was provided, including CCRN (adult,neonatal, pediatric acute), PCCN (progressive care),CCNS (adult, neonatal, pediatric acute clinical nursespecialist), CMC (cardiac medicine), CSC (cardiacsurgery), ACNPC (acute care nurse practitioner),and CNML (certified nurse manager and leader).Any one of these certifications would define theparticipant as AACN certified. Status with respect toother national specialty certifications was assessedin the same manner; that is, a checklist of the spe-cialty certifications was made available and the par-ticipants indicated which certifications they had.Participants who checked any one of the national spe-cialty certifications listed were included in the“other certification” group. Nurses who checked bothan AACN certification and another national certifica-tion were included in the “both certifications” group.

Intent-to-leave variables were determinedthrough participants’ self-reports. Participants wereasked to answer yes or no as to whether they intendedto leave their current position and whether theyintended to leave the nursing profession. If theyanswered yes to either of the intent-to-leave questions,they were then asked to indicate the time frame fortheir intent to leave.

Additional information that was collectedincluded key demographic variables of age, sex, edu-cation, and ethnicity. Also, variables related to pro-fessional work life included position and numberof years in nursing.

Frequencies, percentages, means, and standarddeviations were calculated for the study variables.Both t tests and 1-way analysis of variance were usedto examine differences in empowerment total andsubscale scores with respect to variables of certifica-tion. Chi-square analyses were used to determinedifferences in the intent-to-leave variables betweengroups based on certification status. Additional analy-ses were undertaken to determine the relationshipsbetween key background variables and empower-ment, including position of employment, education,

ethnicity, and sex. Both t tests and χ2 analysis wereused to determine differences in nurses’ intent toleave their current position relative to the variablesof age, sex, ethnicity, and education.

ResultsSample Characteristics

The age for the total sample ranged from 21 to72 years, with a mean age of 44years (SD, 9.94 years). Years of expe-rience ranged from 0 to 51 years,with a mean of 18 years (SD, 10.63years). Characteristics for the totalsample are included in Table 1.

Certification and EmpowermentFor the variable of certification,

respondents were first divided into 2groups: those who held AACN certifi-cation (those who held AACN certifi-cation only and those who heldAACN certification plus other certifi-cation) and those who did not holdAACN certification (those who held other certifica-tion only or those who held no certification).

AACN-certifiednurses were lesslikely to leave theirpositions and weremore empoweredthan nurses who were notAACN certified.

Table 1 Sample characteristics (N = 6589)

Variable PercentageFrequency

Abbreviation: AACN, American Association of Critical-Care Nurses.

SexFemaleMale

EthnicityWhiteAsianHispanicAfrican AmericanOtherUnknown

EducationBachelor’s degreeGraduate degreeAssociate’s degree/diploma

PositionStaff nurseEducatorManagerOtherClinical nurse specialistNurse practitionerDirector of nursing

CertificationAACNNoneBothOther

90.010.0

87.85.23.02.60.80.6

50.727.122.2

64.89.58.07.25.43.51.5

35.828.720.115.3

5929660

57883401991715140

334117851463

4268628526475357233102

2362189413221011



Respondents were divided into 2 groups foranalysis of the position variable: staff nurses andnon–staff nurses (eg, nurse managers, clinical nursespecialists, nurse practitioners, and educators). A t-testanalysis of differences between the 2 groups indicatedsignificant differences in total empowerment scoresand all subscale scores except for the resource sub-scale score. Staff nurses had lower CWEQ-II totaland subscale scores.

Respondents were divided into 3 groups for con-sideration of the education variable: associate’s degree/diploma (n=1463), bachelor’s degree (n=3341), andgraduate degree, which included those who had anymaster’s or doctoral degree (n=1785). Significantdifferences were found in all empowerment scoresin relation to educational level. Participants with grad-uate degrees scored higher on the total CWEQ-IIand all the subscales except the resource subscale.

For ethnicity, respondents were divided into 5categories: white, African American, Hispanic, Asian,and other. One-way analysis of variance revealedsignificant differences between ethnic groups in totalCWEQ-II scores. The highest total empowermentscores were among Asians (mean, 21.76; SD, 3.76),followed by whites (mean, 21.08; SD, 3.80), AfricanAmericans (mean, 21.03; SD, 3.74), Hispanics (mean,20.72; SD, 4.04), and other (mean, 20.16; SD, 5.03).Scores on most CWEQ-II subscales (except for infor-mation and support subscales) differed significantlybetween ethnic groups.

Total empowerment scores and scores on allsubscales except for the support and resource sub-scales differed significantly between sexes. Womenhad higher total empowerment scores and higherscores on the subscales of opportunity, information,formal power (Job Activity Scale), and informalpower (Organizational Relationship Scale).

Intent to LeaveFor the whole sample, 41.1% indicated their

intent to leave their current position; 18.4% indi-cated that they would leave their current positionwithin the next year. Only 6.9% indicated an inten-tion to leave the nursing profession. Of the respondentsintending to leave the profession, the largest per-centage of the total group (3.3%) intended to leavein 3 to 5 years (Table 4).

A significant difference was found in intent toleave current position between respondents whoheld AACN certification (AACN certification or AACNplus other certification) and those who did not haveAACN certification (other certification or no certifi-cation) with χ2 analysis (r=4.70, df=1, P= .05). Thoseparticipants who held AACN certification were less

AACN-certified nurses and nurses not certified byAACN had significantly different total scores on theCWEQ-II (t=-2.73, P= .006) and significantly differ-

ent scores on the subscales of infor-mation (t= -3.40, P= .001), formalpower (t=-2.52, P=.01), and informalpower (t=-8.01, P<.001). AACN-certi-fied nurses had higher total scoresfor empowerment and higher scoreson most of the subscales (Table 2).

In order to examine further thedifferences in empowerment relatedto certification, the sample wasdivided into 4 groups: AACN certi-fied, other (certified by an organiza-tion other than AACN), both(AACN and other certification), andno certification. These 4 groups dif-

fered significantly in total empowerment scores andin scores on the subscales of information, resources,formal power, and informal power. For all of thesignificantly different results, nurses with bothAACN and other national certification or AACN cer-tification alone had higher scores than did nurses inthe other 2 groups (Table 3).

Empowerment Scores as Related to Key Background Variables

Additional analyses indicated significant differ-ences related to the background variables of posi-tion, education, ethnicity, and sex.

Forty-one percentof the critical carenurses indicated

intent to leave theircurrent position;only 7% intended

to leave the profession.

Table 2 Differences in empowerment (CWEQ-II scores)based on AACN certification (N = 6589)

CWEQ-II scale SDMeannCertification t

CWEQ-II score

Abbreviations: AACN, American Association of Critical-Care Nurses; CWEQ-II, Con-ditions of Work Effectiveness Questionnaire, Revised; JAS, Job Activity Scale; ORS,Organizational Relationship Scale.

Total

Opportunity

Information

Support

Resource

Formal power(JAS)

Informal power(ORS)

Non-AACNAACN

Non-AACNAACN

Non-AACNAACN

Non-AACNAACN

Non-AACNAACN

Non-AACNAACN

Non-AACNAACN

29053684

29053684

29053684

29053684

29053684

29053684

29053684

20.9521.21

4.154.14

3.433.52

3.343.33

3.093.07

3.153.21

3.783.93

3.813.81

0.780.78

0.970.97

0.940.95

0.810.81

0.910.92

0.800.76

-2.73

0.37

-3.40

0.36

1.03

-2.52

-8.01

P

.006

.71

.001

.72

.33

.01

<.001



likely to leave their position. When the 4 certificationgroups (AACN only, AACN plus other, other only,and no certification) were compared, intent to leaveposition did not differ significantly among the 4groups (P= .06).

Significant differences (P< .001) were found ontotal empowerment scores and all subscale scoresbetween respondents who intended to leave the cur-rent position and those who intended to leave thenursing profession. In all instances, those who didnot intend to leave either the position or the profes-sion had higher empowerment scores (Table 5).

Nurses who did not intend to leave their positionwere significantly older than nurses who did intendto leave their position (t=10.83, P< .001). Years ofexperience also differed significantly between the 2groups. As the participants’ years of experienceincreased, their intent to leave their current positiondecreased (t=12.45, P< .001). Chi-square analysisof the total sample (n=6589) indicated a significantdifference between the sexes in intent to leave thecurrent position (r=13.44, df=1, P= .01). Of theparticipants who reported intent to leave their cur-rent position, men (47.7%) were more likely toleave than were women (40.3%).

Intent to leave the current position also differedsignificantly among the 5 ethnic groups accordingto χ2 analysis (r=26.89, df=4, P< .001). AfricanAmericans were more likely to leave their positionthan were members of the other 4 ethnic groups.

Chi-square analysis showed a significant differ-ence in intent to leave position related to educa-tional level (N=6589, r=61.45, df=2, P< .001).Respondents with bachelor’s degrees were morelikely to leave their position than were respondentswith any other type of educational preparation.

DiscussionThis study adds to our understanding of specialty

certification in critical care nursing and perceptionsof empowerment. Importantly, the results of the studysupport the value of specialty certification. Significantdifferences were found in total empowerment scoresbetween AACN-certified nurses and nurses not certi-fied by AACN. Also, when the certification variablewas examined further, those nurses who held bothAACN certification and another national certificationhad the highest total empowerment scores. Similarsignificant differences in empowerment scores werefound between certification groups for the subscalesof information, formal power, and informal power.That is, AACN-certified nurses had significantlyhigher scores than did nurses not certified by AACN.Those who held both AACN certification and other

Intend to leave

NoYesIn 1-11 monthsIn the next yearIn 1-2 yearsIn 2-3 yearsIn 3-5 years

Frequency

38832706757452516370611

Frequency

613645363406171218

Percentage

58.941.111.56.97.85.69.3

Percentage

93.16.91.00.60.91.13.3

Table 4 Intent to leave current position andnursing profession (N = 6589)

Current position Nursing profession


Table 3 Differences in empowerment (CWEQ-II scores)according to type of certification (N = 6589)

CWEQ-II scale SDMeannCertification t

CWEQ-II score

Abbreviations: AACN, American Association of Critical-Care Nurses; CWEQ-II, Con-ditions of Work Effectiveness Questionnaire, Revised; JAS, Job Activity Scale; ORS,Organizational Relationship Scale.

Total

Opportunity

Information

Support

Resource

Formal power(JAS)

Informal power(ORS)

NoneAACNOtherBothTotal







18942362101113226589

18942362101113226589

18942362101113226589

18942362101113226589

18942362101113226589

18942362101113226589

18942362101113226589

20.8521.1421.1221.3321.09

4.144.124.164.184.14

3.423.523.463.513.48

3.343.323.363.363.34

3.083.083.123.063.08

3.123.183.223.273.18

3.763.923.803.963.86

3.813.743.813.933.81

0.780.770.780.790.78

0.980.960.940.980.97

0.950.930.920.990.95

0.800.800.810.830.81

0.900.910.930.940.92

0.810.750.790.790.79

4.32

2.05

4.33

0.59

1.24

7.37

22.59

.01

.11

.01

.63

.03

<.001

<.001

P


the e-mail communication and complete the onlinequestionnaire, may reflect a highly involved andcommitted group of critical care nurses. Furthernoted are the significantly higher levels of totalempowerment and higher subscale scores (exceptfor the resource subscale score) for those who arein positions other than staff nurse, compared withstaff nurses. The mean total empowerment score ofthose in other positions would be categorized ashigh empowerment (range for high empowermentis from 23 to 30). This finding is consistent withprevious research in which nurses in managementand leadership positions were reported to have higherlevels of empowerment.14

Although no effort was made in the present studyto determine differences in empowerment betweencritical care nurses in advanced practice roles, itshould be noted that nurses with any graduate degreehad higher total empowerment scores and scores onall subscales (except for support, in which baccalau-reate degree nurses had higher scores) than did nurseswith either baccalaureate or diploma/associate’sdegrees. In future studies, evaluation of the combinedinfluences of advanced education, position, andcertification in relation to perceptions of empower-ment should be continued.

Results for the other background variables, sexand ethnicity, where perceptions of empowermentdiffered significantly between groups, also are note-worthy. Women are the dominant group in nursing

national certification had higher scores on the for-mal power and informal power subscales.

The total empowerment scores of the sample ofcritical nurses in this study was in the moderate range(moderate range for scores is 14-22) for both AACN-certified nurses (mean, 21.21) and nurses not certifiedby AACN (mean, 20.95). These scores exceeded thescores reported in earlier studies conducted byLaschinger and colleagues in which the highest mean

total CWEQ-II score was 19.6, exceptfor the studies of nurse managers, inwhich the CWEQ-II scores rangedfrom 20 to 21.14 In a study15 of 75 crit-ical care nurses conducted in Canada,the mean total CWEQ-II empower-ment score was 17.77. It should be

noted that most of the studies reported by Laschingerand colleagues were conducted in Canada.14 The studyby Piazza and colleagues10 was based in the UnitedStates and had a mean total empowerment score of21.28; that study included staff nurses and nurses atall levels of position (including managers andadvanced practice nurses) in a small community hos-pital. In a recent study16 among critical care nursesfrom 25 intensive care units, Manojlovich and col-leagues studied perceptions of empowerment asrelated to communication between nurses and physi-cians and selected patient outcomes.

The sample in the present study, consisting ofAACN members who were motivated to respond to

Critical care nurseswere moderately

empowered.

Table 5 Differences in empowerment (CWEQ-II scores) between those who intend to leavecurrent position and those who intend to leave nursing profession (N = 6589)

CWEQ-II scale

Total

Opportunity

Information

Support

Resource

Formal power (JAS)

Informal power (ORS)

Intend to leave

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

n

38832706

38832706

38832706

38832706

38832706

38832706

38832706

Mean

22.1219.62

4.293.94

3.663.23

3.563.02

3.202.91

3.412.85

4.003.67

SD

3.533.72

0.700.84

0.920.97

0.890.93

0.790.81

0.870.88

0.730.82

t

27.55a

18.07a

17.31a

23.67a

14.33a

25.62a

17.08a

n

6136453

6136453

6136453

6136453

6136453

6136453

6136453

Mean

22.2319.24

4.163.88

3.503.22

3.372.95

3.102.82

3.212.78

3.883.59

SD

3.773.90

0.770.86

0.961.01

0.940.93

0.800.85

0.910.93

0.780.81

t

10.79a

7.39a

5.95a

9.09a

7.27a

9.83a

7.62a

Abbreviations: AACN, American Association of Critical-Care Nurses; CWEQ-II, Conditions of Work Effectiveness Questionnaire, Revised; JAS, Job ActivityScale; ORS, Organizational Relationship Scale.aP<.001.

Current position

CWEQ-II score CWEQ-II score

Nursing profession



and had significantly higher empowerment scoresthan men had. Asian and white nurses had thehighest empowerment scores; these groups also rep-resent the more dominant ethnic groups in nursing.Nurses who are members of minority groups mayhave higher work stress.

Results Related to Intent to Leave Position and Profession

The large number of participants (n=2706, 41.1%)indicating intent to leave their current position is ofconcern, not only in relation to the financial impli-cations but most importantly in relation to theeffect on the quality of patient care. Adaptations toa new institution are costly to the hospital but alsorequire a reinvestment of energy on the part of theindividual nurse. The learning curve associated withthe change may affect patient care. More than 25%of nurses indicating intent to leave their currentposition said that they intended to leave in the nextyear. It is highly likely that they have already begunthe process of leaving.

Nurses who did not intend to leave their currentposition were significantly more empowered thanwere nurses who intended to leave their position onall dimensions of empowerment measured by theCWEQ-II. This finding is consistent with previousresearch linking these variables directly or relatingintent to leave with job satisfaction.13,17

Significant differences were found betweennurses who intended to leave their position andnurses who did not with respect to the backgroundvariables of age (younger nurses were more likelyto leave), education (nurses with graduate degreeswere more likely to leave than were nurses withbaccalaureate degrees or nurses with diplomas/associate’s degrees), men were more likely to leave,and members of all ethnic/minority groups weremore likely to leave than were whites. These differ-ences warrant further investigation.

Intent to leave current position differed signifi-cantly between AACN-certified nurses and nurseswho were not AACN certified. Importantly, in sup-port of specialty certification for critical care nurses,those with AACN certification were less likely to leavetheir position. Yet when the groups were furtherdivided and nurses with any type of certification werecompared with nurses with no certification, no sig-nificant differences were found. This result may berelated to the group of nurses who had other certifi-cation, including those who have specialty and gen-eralist certification, not just specialty certification. Italso may be that AACN-certified nurses have a highlevel of engagement in their professional organiza-

tion and that their certification and engagement aredirectly related to the work activities in critical careunits. This finding regarding differences in intent toleave related to AACN specialty certification is differ-ent from the findings of the national study acrossspecialty groups. Niebuhr and Biel11 reported thatspecialty certified nurses (across a wide range of nurs-ing specialties) and noncertified nurses did not indi-cate differences in intent to leave their positions.

One of the important findings of this study wasthe high percentage (93.1%) of critical care nursesindicating that they did not intend toleave the profession. This variablehad not previously been studied in anational sample of critical carenurses. In relation to the design ofretention programs for critical carenurses, it is important to understandthat even though a larger percentageof critical care nurses might want toleave their current position, they intend to stay inthe profession. Nurse managers and hospital execu-tives should consider ways to retain the nurses intheir positions, including programs that might allowthem to step back from the highly demanding envi-ronment for short periods. No effort was made inthe current study to determine reasons for leavingeither the position or the profession. Certainly thesereasons should be investigated in future research,particularly in order to understand the reasons thatcritical care nurses might offer for their intent toleave the current position but not the profession.

LimitationsThis study had several limitations. First, the par-

ticipants were only those critical care nurses forwhom AACN had e-mail addressesavailable. Also, nurses whoresponded to the survey requestmight have been those nurses whoare more likely to be certified as wellas those who are more empoweredcompared with the general popula-tion of critical care nurses. Further, noeffort was made to distinguishbetween types of certification otherthan in a very general manner byself-report of the respondents. That is, all AACN typesof certification were included together, and all othernational specialty certifications were included together.

ConclusionThis study adds to the literature on specialty

certification as related to both perceptions of

Nurses with AACNcertification wereless likely to indicate intent toleave their position.

Women and Asianand white nurseshad higher empow-erment scores.



REFERENCES1. American Association of Critical-Care Nurses. Certification.

http://www.aacn.org/DM/MainPages/CertificationHome.aspx.Accessed January 22, 2010.

2. Wade CH. Perceived effects of specialty nurse certification: areview of the literature. AORN J. 2008;89(1):183-188, 190-192.

3. Kanter RM. Men and Women of the Corporation. New York, NY:Basic Books; 1993.

4. Laschinger HK. A theoretical approach to studying work empow-erment in nursing: a review of studies testing Kanter’s theoryof structural empowerment in organizations. Nurs Admin Q.1996;20:25-41.

5. Laschinger HKS, Havens DS. Staff nurse work empowermentand perceived control over nursing practice: conditions for workeffectiveness. J Nurs Adm. 1996;26(9):27-35.

6. Laschinger HKS, Finegan J, Shamian J, Casier S. Organizationaltrust and empowerment in restructured healthcare settings: effectson staff nurse commitment. J Nurs Adm. 2001;30(9):413-425.

7. Laschinger HK, Finegan J, Shamian J. The impact of workplaceempowerment organizational trust on staff nurses’ work satis-faction and organizational commitment. Health Care Manag Rev.2001;26:7-23.

8. Leiter MP, Laschinger HKS. Relationships of work and practiceenvironment to professional burnout: testing a causal model.Nurs Res. 2006;55:137-146.

9. Manojovich M, Laschinger H. The Nursing Worklife Model: extend-ing and refining a new theory. J Nurs Manag. 2007;15(3):256-263.

10. Piazza IM, Donahue M, Dykes PC, Quinn Griffin MT, FitzpatrickJJ. Differences in perceptions of empowerment among nation-ally certified and noncertified nurses. J Nurs Admin. 2006;36(5):277-283.

11. Niebuhr B, Biel M. The value of specialty nursing certification.Nurs Outlook. 2007;55(4):176-181.

12. Ulrich BT, Lavandero R, Hart KA, Woods D, Leggett J, Taylor D.Critical care nurses’ work environments: a baseline status report.Crit Care Nurse. 2006;26(5):46-57.

13. Zurmehly J, Martin PA, Fitzpatrick JJ. Registered nurses empow-erment and intent to leave current position and/or profession.J Nurs Manag. 2009;17(3):338-391.

14. Laschinger HK. UWO Workplace Empowerment Research Pro-gram 1992-2004. http://publish.uwo.ca/~hkl/descrip.html.Accessed January 22, 2010.

15. Tigert JA, Laschinger HK. Critical care nurses’ perceptions ofworkplace empowerment, magnet hospital traits, and mentalhealth. Dynamics. 2004;15(4):19-23.

16. Manojlovich M, Antonakos CL, Ronis DL. Intensive care units,communication between nurses and physicians, and patientoutcomes. Am J Crit Care. 2009;18:21-30.

17. Frank-Stromberg M, Ward S, Hughes L, et al. Does certificationstatus of oncology nurses make a difference in patient outcomes?Oncol Nurs Forum. 2002;29(4):665-672.

18. Ulrich BT, Woods D, Hart KA, Lavandero R, Leggett J, Taylor D.Critical care nurses’ work environments: value of excellence inBeacon units and Magnet organizations. Crit Care Nurse. 2007;27(3):68-77.

19. Donahue M, Piazza IM, Quinn Griffin MT, Dykes PC, FitzpatrickJJ. The relationship between nurses’ perceptions of empower-ment and patient satisfaction. Appl Nurs Res. 2008;21(1):2-7.

empowerment and intent to leave. In addition,and importantly, the results support the findingsof recent research on critical care nurses’ percep-tions of their work environments in which theresearchers reported that most nurses were verysatisfied with nursing as a career18 and the rela-tionship between empowerment and retention ofnurses.13 Important additions to the literature arethe findings regarding differences in empower-ment related to specialty certification. The prepa-ration and subsequent retention of a highlyqualified and committed specialty nursing workforce is key to high-quality patient care andsmooth functioning of health care organizations.Certified nurses offer knowledge, experience, and

confidence to the institution.Nurse administrators and healthcare executives have an opportu-nity to create structures thatreward nurse involvement and par-ticipation within the organizationand should encourage professionaldevelopment through certification.

Recommendations for Future Research

Ultimately, the goal forresearch related to certification is

to connect the value of certification to patients’outcomes. Links between certification and patients’outcomes have been studied indirectly.17,19

Research that directly addresses this potential rela-tionship is recommended. In addition, the directlink between empowerment and nurse retentionmust be found.

Some of the additional analyses in the pres-ent study warrant future extensive examination.One example is the significant differences inboth empowerment and intent to leave related toethnicity. It is important to develop better under-standings of these dimensions among respon-dents from underrepresented cultural groups innursing. Future research should be focused ondetermining why these differences occur.

FINANCIAL DISCLOSURESThis study was funded by the American Association ofCritical-Care Nurses Certification Corporation.

To purchase electronic or print reprints, contact TheInnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,(949) 362-2049; e-mail, [email protected].

Additionalresearch focusedon strategies forretention of highlyqualified critical

care nurses is needed.

eLettersNow that you’ve read the article, create or contribute to anonline discussion on this topic. Visit www.ajcconline.organd click “Respond to This Article” in either the full-text orPDF view of the article.



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CE Test Test ID A1019032: Certif ication, Empowerment, and Intent to Leave Current Position and the Profession Among Critical Care Nurses. Learning objectives: 1. Determine the relationship between AACN specialty certification and empowerment. 2. Identify the relationship between certification,empowerment, and intent to leave current position and the profession. 3. Evaluate the value of AACN specialty certification and retention of staff.

Program evaluationYes No

Objective 1 was met � �Objective 2 was met � �Objective 3 was met � �Content was relevant to my nursing practice � �

My expectations were met � �This method of CE is effectivefor this content � �

The level of difficulty of this test was: � easy �medium � difficult

To complete this program, it took me hours/minutes.

1. What is certif ication?a. The process of becoming a registered nurse through state licensureb. A nongovernmental agency validates a nurse’s qualification for and knowledge of practice

c. The process of graduating from an accredited baccalaureate program d. The completion of a 12-week orientation class at a hospital’s unit

2. Which of the following is not a reason to retain critical care nurses in theircurrent position?a. They are highly skilled.b. They are difficult to replace.c. They receive a high salary.d. They are costly to replace.

3. Why was nurses’ intent to leave studied in this research?a. It was an indirect assessment of retentionb. The researchers’ grant for the study required itc. To validate the previous study of this variabled. It is part of a synergistic relationship

4. Which of the following theorists states that employees who have access toempowerment structures have greater work effectiveness?a. Nightingaleb. Kanterc. Browningd. Fields

5. Which of the following was a research question in this study?a. Are there similarities in perceptions of structural empowerment between AACN-certified nurses and those who are not AACN certified?

b. Are there differences in intent to leave (current position and the nursing profession) between AACN-certified nurses and those who are not AACN certified?

c. Are there differences in perceptions of empowerment between certified nurses and those who are not certified?

d. Are there similarities in intent to leave (current position and the nursing profession) between certified nurses and those who are not certified?

6. Why was the sample chosen also a limitation of the study?a. Only nurses with e-mail addresses were contacted.b. Only critical care nurses were contacted. c. Only AACN members with e-mail addresses were contacted.d. Only CCRN members with e-mail addresses were contacted.

7. Which of the following types of nurses responded in greatest number to thissurvey?a. Staff nursesb. Educatorsc. Managersd. Clinical nurse specialists

8. Which of the following statements is true?a. AACN-certified nurses were less likely to leave their positions and were more empowered than nurses who were not AACN certified.

b. AACN-certified nurses were more likely to leave their positions and were more empowered than nurses who were not AACN certified.

c. AACN-certified nurses were less likely to leave their positions and were less empowered than nurses who were not AACN certified.

d. AACN-certified nurses were more likely to leave their positions and were less empowered than nurses who were not AACN certified.

9. Which of the following statements is true?a. Participants with graduate degrees scored lower on the total Conditions of Work Effec-tiveness Questionnaire, Revised (CWEQ-II), and all subscales.

b. The highest total empowerment was among Asians, followed by whites, African Americans, Hispanics, and other.

c. Staff nurses had the highest scores in CWEQ-II total and subscale scores.d. There was no difference between the sexes in total empowerment scores.

10. Which of the following groups had the highest total empowerment scores?a. Nurses not certified by AACNb. Certified AACN nursesc. AACN certified nurses who also had another national certificationd. None of the above

11. The total empowerment score for this sample of critical care nurses waswhich of the following?a. Low c. Highb. Moderate d. Not discussed

12. Which of the following statements is true?a. Older nurses were more likely to leave their position.b. Nurses with graduate degrees were more likely to stay in their position.c. Men were more likely to leave their position.d. Whites were more likely to leave their position.

For faster processing, takethis CE test online at

www.ajcconline.org (“CEArticles in This Issue”) ormail this entire page to:AACN, 101 Columbia, Aliso Viejo, CA 92656.

Fee: AACN members, $0; nonmembers, $10.50 Passing score: 9 Correct (75%) Synergy CERP: Category C Test writer: Jane Baron, RN, CS, ACNP

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACNprogramming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Test ID: A1019032 Contact hours: 1.25 Form expires: May 1, 2012. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

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