By Marilyn Hanchett, RN, MA, CIC
Certification programs in healthcare were developed to demonstrate competency within a specific field. In regulated professions such as medicine and nursing, certification demonstrates proficiency above and beyond the knowledge and skills required for licensing. Over previous decades, this initial concept has expanded. Certifications are now widely used to showcase specialized, and sometimes advanced, proficiency in a wide variety of fields. This change has been driven by the ever evolving nature of healthcare, the demands of accrediting and regulatory bodies for valid processes to verify practitioner competency, and the lucrative source of revenue these programs provide to their providers.
The infection prevention and control community has been involved in this process. The first and only national certification program was launched by APIC through its subsidiary the Certification Board of Infection Control and Epidemiology Inc. (CBIC) over 30 years ago. The CIC® credential is the widely recognized certification for infection prevention and control in North America and remains a priority within APIC’s 2020 Strategic Plan. In fact, the APIC Scorecard, the document that established metrics for its strategic goals released in 2012, targets certification of 10,000 infection preventionists by 2012.
Numerous and often complex issues impede the attainment of that ambitious target. Factors such as the cost of certification, time and costs for test preparation, low passing rates during initial testing, high turnover, and the lack of reimbursement by employers or no salary incentive for those earning the CIC® are challenging barriers. It is important to note that these are common obstacles among most organizations sponsoring voluntary certification programs. And most organizations, including APIC, must also address the escalating retirement rate among long time credentialed members. The unfortunate effect of the current situation is that national discussion is usually preoccupied with issues of volume: how many individuals are seeking certification, how many renew, what is the ratio of retiring CICs to those initially certifying. The immediacy of a volume focused conversation overshadows other new and emerging issues within credentialing programs, any of which have the power to significantly change certification.
There are currently three trends of which infection preventionists should be aware.
1. Expansion of Sponsoring Organizations
For three decades infection preventionists have only had access to a generalist credential. While the scope of the CIC® has been expanded over time to make it more applicable to IPs in non-hospital settings, its generalist orientation means that IPs employed outside acute care must maintain proficiency in acute care topics and/or that content specific to nonhospital settings is at risk of insufficient inclusion in the examination process. For example, the infection control issues of the IP who works predominantly in acute and critical care will be different from the individual employed in behavioral health. The IP who consults with the county’s school nurses will not be identical to the IP who is assisting ambulatory surgery centers.
The rationale for the generalist credential is that a certified IP must be qualified to work in any setting. However, there is no evidence that neither support nor refutes this claim. And it appears to contradict national trends among other credentialing organizations that offer highly specialized rather than general programs. Empiric and anecdotal evidence reports resistance among IPs who work outside of hospitals to demonstrating competency in topics they do not use.
The IP profession, when categorized according to its potential practice settings, is far reaching. And a rapidly aging population, with its expanding demand for non-acute services, will add to the types of settings in which IPs will be needed. To respond to these needs, the National Association of Directors of Nursing Administration in Long Term Care (NADONA) announced in 2016 its plans to launch an infection prevention credential specific to long term care. Based on national trends, it is likely that other practice setting specific options may emerge. Just as the American Nurses Association has over time watched the many nursing specialty organizations compete successfully for certificants, CBIC may be witnessing the beginning of a similar change among APIC members.
2. Micro credentialing
Micro credentialing is a process that verifies a specific competency. It is gaining popularity within the educator community and is well established with the Information Technology field; it has not yet spilled over into infection prevention and control. Micro credentialing programs, however, are well suited to the infection prevention arena. They are most often adaptable to online processes, can be offered in or outside of formal academic settings, and help professionals refine specific skill sets. Micro credentials can be developed and sponsored by a range of qualified providers which may include but are not necessarily limited to professional membership organizations. Typical programs include an earned “badging” system, which recognizes successful completion immediately. Participants can earn additional micro credentials as they progress through various modules and competency based exercises at their own rate.
Micro credentialing offers a unique opportunity for infection prevention content to expand its content to other disciplines. This is important because the IP function, outside the hospital, is usually integrated into one or more other roles. While it is unlikely that the individual who must juggle multiple roles and priorities can obtain the CIC®, micro credentials in any number of specific topics may be ideal. Conversely, the IP who holds the CIC® could supplement that certification with micro credentials that focus on additional or emerging topics. The opportunity to integrate micro credentials into existing certification approaches is an intriguing topic for proponents of newer competency -based approaches. It may well hold out the promise of the most radical change in the approach to credentialing since certification programs were first developed.
For the near future, a few examples in which micro credentialing could be a useful and practical adjunct to infection control and patient safety science include safe handling and processing of endoscopes, needle and other sharps safety, obtaining and handling of laboratory specimens, basic surveillance and reporting skills, and basic competency in using the CDC’s NHSN system. However, the actual variety of topics suitable for this approach will vary according to practice site and individual participant demands, both of which continue to evolve and change.
3. The Portfolio Approach
A third and less obvious trend is the acknowledgement by organizations that not all competency is best assessed by examination. Although the traditional national examination of 100 or more items remains the mainstay of certification, submission of a professional portfolio (a compendium of personal activities and achievements organized according to predetermined standards and goals) is beginning to offer an alternate approach.
This methodology is not only highly personalized; it recognizes that not all competencies can be quantified. Scientific and technical data, along with accepted evidence and facts, can be readily used in measurement and testing. But other dimensions of professional practice are far more complex to measure, let alone measure reliably. In these cases, evidence of competency in both knowledge and skills must be derived from sources other than testing.
The portfolio concept has some precedent. For example, some healthcare certification boards accept a combination of designated activities (e.g. continuing education units, research activities, college level courses, publications, major presentations, etc.) for recertification. In academia, graduate level capstone projects may offer a “portfolio option” in lieu of the traditional thesis. In these examples the portfolio option recognizes that competency can be demonstrated in variety of ways that these may be different but are equally valid, and that different types of outcomes from learning and professional development are as important to competency as knowledge acquisition.
The foremost example of this trend is seen at the American Nurses Association. The American Nurses Credentialing Center now offers a number of certification by portfolio options. For IPs who are RNs, the ANCC’s credential for Advanced Public Health Nurse, available since 2014, may offer a helpful new choice.
Other options could include offering an advanced IP certification based on portfolio or similar assessment method. Or this type of approach could be adapted to offer a more specialized credential for a targeted bundle of skills. For example, while education is a major component of the IP role, the number of IPs who have received any form of pedagogical preparation is unknown. Assessment of teaching ability does not lend itself readily to a formal exam but could be demonstrated via other forms of evidence. The competency of IP consultant might also be credentialed in this manner. As new variations on the IP continue to emerge, especially for advanced practice, non-test based methods may offer the most realistic and relevant option.
As these emerging trends show, the traditional or one-size-fits-all approach to IP certification is changing. The tipping point for major change has not yet been reached but is approaching. This impending change need not be seen as a threat. In fact, as these trends indicate, change offers the opportunity to reach a much broader audience and expand the impact of infection prevention and control in ways that were neither possible nor practical in preceding decades.
The immediate challenge for all IPs is to join the certification discussion, not only regarding the numbers of IPs certified or the relevance of the current credential, but also how credentials are developed. Most importantly, the discussion needs to focus on where the profession wishes to be in 5-10 years and how new credentialing options can be used to help attain that vision.