RESEARCH AND PRACTICE
Nurses’ Utilization and Perception of the Community/Public
Health Nursing Credential
Betty Bekemeier, PhD, MPH, RN
Several public health disciplines have devel-
Objectives. I explored the underutilization of the community/public health
oped certification or registration programs
nursing (C/PHN) credential by examining the individual characteristics of public
during the past century. These include the health nurses, the value these nurses perceive for certification, the barriers they
Registered Environmental Health Specialist or perceive to obtaining or maintaining a C/PHN credential, and their credential
Registered Sanitarian (REHS/RS) credential in status.
1937, the Community Health Education Spe- Methods. I surveyed a national sample of 655 public health nurses regarding
cialist (CHES) certification in 1989, the Public this more than 20-year-old credential. I analyzed variables related to perceived
Health and General Preventive Medicine cer- value, barriers, and characteristics of public health nurses.
tification (for physicians) in 1983, and certifi- Results. The perceived value of credentialing did not differ among public
cation for public health nursing in the early health nurses relative to whether they had ever had a C/PHN credential. The
1980s. In recent years, discussion has in- C/PHN credential, however, was obtained significantly more often by public
health nurses in academic settings than by those working in practice settings.
creased regarding the potential benefits of a
Conclusions. The C/PHN credential appears to be disproportionately underu-
system for credentialing the general public
tilized and unknown to public health nurses in the practice community. Findings
health workforce, and indeed, the first public suggest, however, that utilization could be improved by increasing the creden-
health credentialing exam was given in August tial’s visibility outside of academic environments and by establishing system-
2008.1 At the same time, a lack of empirical level changes that provide external recognition, such as salary increases and
research has left the public health community career advancement, for specialty credentials. (Am J Public Health. 2009;99:
divided on the perceived value, benefits, and 944–949. doi:10.2105/AJPH.2008.150029)
barriers related to credentialing as an appropri-
ate measure for ensuring a competent work-
force.2–5 Researchers and public health leaders specific barriers to credentialing include chal- public health workforce widen, it has become
involved in establishing the broader public lenges related to cost, agreement on standards, even more critical to understand the per-
health research agenda recognize that little sub- workforce acceptance, and workforce diver- ceived value of credentialing to public health
stantive research has been conducted regarding sity.3,16 Only limited and inconclusive research workers and the factors related to what sup-
the benefits of a credentialed workforce and has been conducted on these issues.17 ports or hampers the utilization of specialty
the structures most effective for supporting the Several studies have profiled credentialed credentials in public health. Public health
process.3,6,7 As a result, research regarding specialty groups12,18,19 and have examined dif- nurses have had access to a specialty cre-
credentialing has been made a national agenda ferences between credentialed and noncreden- dential for more than 20 years. In 2005,
item.8 tialed professionals.9,12–15,19,20 None of these however, nurses recognized for their spe-
The limited empirical evidence regarding studies examined public health nurses, but their cialization in public health through
credentialing is largely positive, and published findings suggest the potential for relations to exist credentialing faced the potential discontinu-
commentaries overwhelmingly describe it as a between individual characteristics of nurses or ation of their credentialing process because
constructive investment. Commentaries re- public health workers, how they perceive the of low participation rates.23 No one knows
garding health profession–related credential- value of and barriers to credentialing, and exactly why this public health nursing cre-
ing frequently cite personal benefits for the whether they are credentialed. The research dential has been underutilized and what this
credentialed professional such as increased job literature suggests that workplace role (as a could mean for efforts to credential the
satisfaction, challenge, and personal achieve- frontline staff nurse),12 race and ethnicity (as a broader public health workforce. To date, the
ment.9,10 The actual research studies related to nonminority),21 geographical setting (in a non- Community/Public Health Nursing (C/PHN)
empirically measuring this, however, have been rural area),22 age (as an older professional),9,21 credential has largely survived its 2005 threat
varied and inconclusive.11–15 and education (having less-advanced educa- of discontinuation but has not seemingly
Whereas little conclusive research evidence tion)19 can positively affect how nurses value achieved its full potential for acceptance
exists regarding the value of credentialing, even credentialing and might have significant positive among a broad constituency of nurses in our
less research has been conducted regarding the relations with credential status.22 public health workforce. Nurses make up the
barriers to obtaining or maintaining a creden- As discussions related to the credentialing largest single discipline in public health,24 and
tial. Published commentaries indicate that of public health nurses and the broader lessons can be learned from them regarding the
944 | Research and Practice | Peer Reviewed | Bekemeier American Journal of Public Health | May 2009, Vol 99, No. 5
, RESEARCH AND PRACTICE
implementation of a broader public health www.astdn.org). As a result of their affiliations Perceived Barriers Related to
worker credential. with national organizations, the participants Credentialing
Based on a review of the literature and were perceived to be a representative sample The frequency and ranking of barrier items
ongoing national discussions, I designed a sur- of public health nurses in positions of some that participants perceived in relation to
vey and used cross-sectional research methods level of veteran or emerging leadership and obtaining and maintaining the C/PHN cre-
to examine relations between the individual with some awareness of broad public health dential were used to develop respondents’
characteristics of public health nurses, the nursing issues. barrier-intensity scores. The number of times a
value they perceive for certification in general, barrier item was chosen from among the 16
the barriers they perceive to obtaining or Individual Characteristics barriers determined the frequency of an item
maintaining a C/PHN credential, and their According to the available literature, several being chosen. The average ranking assigned
credential status. I expected that identifying characteristics of public health nurses are po- to a barrier item by participants determined
apparent differences between those who tentially related to their perceptions of the that item’s overall ranking. Barrier-intensity
obtained the credential and those who did not value of credentialing, the barriers they per- scores were determined by the degree to which
would help to explain some of the underutili- ceive regarding the C/PHN credential, and specific barriers were ranked most highly and
zation of this established credential. their credential status. Therefore, I examined most often by respondents. Ultimately, the
the workplace role, population size of the work barrier intensity scores represented 2 features
METHODS setting, and the age, race/ethnicity, and edu- of the data: the frequency with which a re-
cation of the participants.9,12,19,21,22 These spondent indicated items and the nature of
I collected anonymous data in March 2006 characteristics were measured largely as cate- how the study sample as a whole ranked the
through a self-report, Web-based survey in- gorical or ordinal variables captured through items. This approach took into account how
strument titled the Value of a Community/ demographic data. Some of the variables (i.e., many items a respondent checked an item,
Public Health Nursing (C/PHN) Credential. education, professional role, workplace, race/ what items they checked, and what items they
The survey included a value scale, a barriers ethnicity) were ultimately adapted during the did not check. This approach was supported
scale, and demographic questions. The value analysis to combine similar responses and create by the broad range of scores and the normal
scale assessed the respondents’ perceived value dichotomous variables for ease of interpretation. distribution curve that the resulting data
of nursing certification and was measured with Finally, the credential status of each participant produced.
the well-tested 18-item Perceived Value of was also collected and defined dichotomously Ultimately, the scales for the perceived
Certification Tool (PVCT), used with permis- as having ever obtained a C/PHN credential at value of credentialing and for the perceived
sion from the scale authors. Respondent an- the basic (undergraduate level) or advanced barriers to obtaining and maintaining a C/PHN
swers for each item ranged from strongly agree (postmaster level)—either currently holding the credential produced 3 continuous scores for
to strongly disagree.25 Reports on the reliability credential or having held it previously—or as each participant: intrinsic value, extrinsic value,
of the PVCT indicated that it had consistently having never obtained the credential. and barrier intensity. I used these 3 scores
attained a scores of 0.90 or more.25,26 I modi- to further examine which factors might be
fied an existing survey tool from the National Perceived Value of Credentialing associated with lack of utilization of the
Certification Board of Pediatric Nurse Practi- The perceived value placed on credentialing credential.
tioners and Nurses to develop a 16-item barriers was measured with the PVCT by using the
scale that measured perceived barriers to same factors identified by Sechrist et al.26— RESULTS
obtaining and maintaining a C/PHN credential. personal or intrinsic value and external or ex-
The respondent sample of 655 was made up trinsic recognition by others—and had an a score Although mostly White and middle aged or
of public health nurse members of the listserves of 0.948. After exploratory factor analysis was older, the participants in the study represented
of any of the 4 organizations of the Quad conducted and the number and type of factors public health nurses working in a variety of
Council of Public Health Nursing Organizations: were confirmed, the respondents were given settings, practicing in a variety of roles, serving
the Public Health Nursing Section of the Amer- continuous scores for each of the 2 identified rural and urban communities, and representing
ican Public Health Association (http://www. factors related to the perceived value of several racial/ethnic groups (Table 1).
apha.org/membergroups/sections/aphasections/ credentialing. The intrinsic value factor repre- Pearson correlation analysis of the variables
phn), the American Nurses Association’s Con- sented what respondents perceived to be the under examination indicated significant mod-
gress on Nursing Practice and Economics level of personal value related to challenge, erate to high correlations between the intrinsic
(http://www.nursingworld.org/MainMenu satisfaction, and growth provided to public and extrinsic value scores (r = 0.667; P < .001)
Categories/ThePracticeofProfessionalNursing/ health nurses by credentialing. The extrinsic and between the value and barrier scores
NewCNPE.aspx), the Association of Commu- value factor represented the level of external (extrinsic value and barrier intensity: r =
nity Health Nurse Educators (http://www. value related to market and professional recog- –0.317; P < .001; intrinsic value and barrier
achne.org), and the Association of State and nition provided to public health nurses by intensity: r = –0.252; P < .001). No significant
Territorial Directors of Nursing (http:// credentialing.27 correlations existed, however, between those
May 2009, Vol 99, No. 5 | American Journal of Public Health Bekemeier | Peer Reviewed | Research and Practice | 945
