The Right Time for Certification

Abstract

Sometimes new nurses ask me when is the best time in one’s nursing career to pursue certification. Can a new graduate nurse take the CCRN or PCCN examination or is it better to wait several years? This is a personal decision and the timing may be different for everyone, but minimum criteria are laid out in the exam handbooks. For many certifications (ie, CCRN, PCCN, CSC, CMC), the nurse must have at least 1750 hours in practice as a registered nurse or advanced practice registered nurse providing direct care to the pertinent patient population (please refer to the exam handbook for details).1 A nurse working 36 hours per week would accrue those hours in 48.6 weeks, so I usually advise nurses that they need about a year of experience. For new graduate nurses or nurses new to the specialty, the first year is usually filled with the challenge of learning to be a critical care nurse. The criterion of 1750 hours is meant to correspond to the third stage of Benner’s stages of clinical competence: a nurse often transitions from advanced beginner to competent nurse with approximately 1 year of experience.2 The certification exam questions are aimed to verify this level of competence. My personal experience agrees with Benner’s framework. Nearly a year after orientation in the intensive care unit, I noticed a transition from feeling anxious each shift about whether I could handle whatever I might encounter to feeling more confident that I could handle whatever happened with the support of my team. I’ve seen many nurses in the second year of critical care practice reach a stage in which taking on a new challenge feels exciting and possible instead of stressful and overwhelming. I think that is the perfect time to pursue an additional goal such as certification. When multiple incompatible intravenous medications need to be given to a critically ill patient, finding enough vascular access sites can be a challenge. Placing a new peripheral intravenous catheter is the safest option of those presented. This approach will ensure that incompatible medications are not allowed to mix (A) and potentially form precipitates, which may plug the lumen and limit central access. Although some pulmonary artery catheters include an infusion port, others do not, and it is important to avoid infusing medications into incorrect ports. Infusing medications into the pulmonary artery (B) has not been studied, so without safety information, infusing a medication into the distal pulmonary artery catheter port is not advised. The balloon inflation port (D) should only be used to inflate and deflate the balloon at the end of the catheter. This lumen does not access the bloodstream and no infusion should ever be given into this port.Incivility in health care teams is a problem that impacts not only the workers but also the patients because poor teamwork can affect patient outcomes. A team’s ability to treat each other well is influenced by an organization’s tolerance of unacceptable behaviors. Reporting acts of incivility and bullying is important so an organization can track and treat the problem. It would be prudent in this situation for the nurse to follow up with the new peer to ensure their questions have been answered. By using skilled communication, the nurse may have the ability to defuse the situation and improve unwanted actions, but loud and aggressive communication can create a more hostile environment (B). Ignoring incivility can condone the behavior, encourage the behavior to continue, and prevent leaders from understanding the issues at hand (C). Skilled communication with peers would involve using nonthreatening methods to help new staff members who are searching for answers (D). Communication with new staff members should encourage, not stifle, questions.Preparing a patient physically and mentally for medical procedures can help build a trusting relationship between nurse and patient. Tests can cause pain, discomfort, and fear. Patients with anxiety disorder may find the confined space or loud sounds of a traditional MRI machine distressing. Knowing this, a nurse may advocate for supplies (eg, ear plugs, eye mask, call bell) or anxiolytic medications to make the MRI procedure more tolerable. A history of hypertension (A), renal calculi (B), or liver cirrhosis (C) will not require any special interventions from the nurse.During cardiogenic shock, the goal of therapy should be to make it easier for the heart to pump blood. Afterload, meaning the force required to overcome resistance to ejecting blood out of the left ventricle, should be decreased (not increased) (A). When the heart’s workload is decreased through reduced afterload and preload, myocardial oxygen demand is decreased (not increased) (A). Due to decreased contractility in cardiogenic shock, the heart is relatively volume overloaded even if the patient is technically euvolemic. Preload, or the volume of blood and therefore the pressure created in the left ventricle at the end of diastole, should decrease (not increase) when appropriate therapy is administered (B). Increasing (not decreasing) contractility should also be a goal of cardiogenic shock treatment (D).Amniotic embolus is a rare medical emergency that often presents as cardiac arrest. Manually displacing the uterus to the left relieves pressure on the inferior vena cava to permit adequate venous return. Continuous lateral displacement of the uterus is vital throughout the cardiac arrest event and may be best achieved by assigning 1 team member to this important task. Extracorporeal membrane oxygenation may be considered in a patient with a prolonged resuscitation attempt, but this would be venoarterial ECMO, which is used for cardiac failure, and not venovenous ECMO, which would be used for respiratory failure without cardiac failure (B). Following initial resuscitation, the focus should shift to care of right ventricular failure, uterine atony, and disseminated intravascular coagulation. Some patients experience hemorrhage related to disseminated intravascular coagulation, but a careful balance of resuscitation should be considered due to the right ventricular failure and tenuous fluid balance. A slightly altered massive transfusion protocol favoring cryoprecipitate over plasma and accompanied by tranexamic acid may be activated, but this is not the highest priority for initial management (C). The diagnosis is usually made with echocardiography (D).A dissection of the ascending portion of the aorta can extend to the coronary and arch vessels and the aortic valve, causing various acute complications, including aortic regurgitation. Aortic regurgitation causes a diastolic murmur heard best in the second intercostal space at the right sternal border (over the aortic valve). A new finding of aortic regurgitation in a patient with a thoracic aortic aneurysm would be a sign of dissection and an indication for emergency surgical repair. Janeway lesions (A) are nontender erythematous or hemorrhagic macules on the palms and soles and are indicative of infectious endocarditis. The Rovsing sign (B) involves pain in the right lower abdominal quadrant when the left lower quadrant is palpated and is a sign of acute appendicitis. Systolic murmurs (D) are associated with diagnoses such as aortic stenosis and mitral regurgitation, neither of which is likely in a patient with aortic dissection. The pulmonic valve, which is not likely to be affected by aortic dissection, is best auscultated in the second intercostal space at the left sternal border, not the third intercostal space.Protective dressings made of soft foam or silicone provide a cushioning layer that may help mitigate injury-inducing forces from reaching the skin. Prophylactic dressings do not take the place of turning or off-loading, but they may be used to reduce friction and shear. Evidence suggests applying these dressings to bony prominences such as the sacrum and heels before any signs of injury occur in patients who are at high risk for pressure injury. Moisture (A) increases friction and the risk for skin injury, so skin and linens should be kept dry. Massage (B) can create a shearing force by stretching fragile skin tissues, possibly leading to skin layer separation and blood vessel tearing or twisting. Rough surfaces such as standard hospital sheets and transfer boards (C) can contribute to friction and shear. Instead, the use of friction-reducing synthetic sheets and air-transfer devices may decrease friction and shear.Epoprostenol is a strong vasodilating agent that can be used as a long-term intravenous infusion to treat pulmonary hypertension. Epoprostenol is considered a high-alert medication because it has a short half-life and interruptions in therapy can have life-threatening consequences. Octreotide (B), a vasoconstricting agent that reduces splanchnic blood flow to control variceal bleeding, has a longer half-life, so a brief interruption in therapy is less dangerous for the patient. Regular insulin (C) is considered a high-alert medication, but hyperglycemia from an interruption in therapy is not immediately life-threatening. Amiodarone (D) has the longest half-life of the medications listed, so a brief interruption of this infusion is least likely to cause harm.It is important to validate the emotions of a patient with dementia and, when possible, to give the patient autonomy and an opportunity to express concerns. Broad (instead of direct) questions may be helpful. Feelings may be more important than facts to patients with dementia, so using logic (A) may be perceived as confrontational and result in negative communication. Reorienting the patient may be seen as a contradiction to the patient’s current reality and cause increased agitation (C). Elder-speak (D), which includes exaggerated terms of endearment or an assumption that the patient is helpless, may be perceived as disrespectful and should be avoided.In patients with mild to moderate acute pancreatitis, early oral food intake is safe and usually well tolerated. Evidence indicates that a soft oral diet is safe even if lipase and amylase levels are elevated (B). Early oral feeding contributes to shorter stays compared with keeping patients on nothing-by-mouth status until enzyme levels are decreased (B) or pain is resolved (C). Low-fat, soft foods are recommended as they can provide more calories than clear liquids (C) and are equally well tolerated. Parenteral nutrition (D) is associated with higher rates of complications and mortality than is enteral nutrition for patients with acute pancreatitis and therefore should only be used if a patient cannot tolerate or has a contraindication to enteral nutrition (eg, paralytic ileus or mesenteric ischemia).AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.