Certification of Pediatric Oncology

Nurses: From Roundtable Discussion

to Reality
Holly Ann Williams, RNC, MN, CPON,
Leslie Wagner McMahon, RN, MSN, CPON,
Beth Frederick Hasenauer,RN, MS, CPON,
Penny Pennoyer, RN, CPON, OCN, and
Karla Wilson, RN, MN, CPON, OCN

Certification for pediatric oncology nurses became a reality in 1993 when the
first national certification examination was administered in Rena, NV. Some
members of the Association of Pediatric Oncology Nursing initially voiced an
interest in certification at a roundtable discussion held during the 1988 annual
meeting. The momentum lead to the formation of a task force to initiate the
certification process. The task force led to an ad hoc committee, organized to
design and implement certification. Certification is now overseen by the Certifi-
cation Corporation of Pediatric Oncology Nurses. The benefits of certification
and a historical overview of pediatric oncology nursing certification is discussed
in this article. Details of how the test was designed are offered, as well as results
from the pilot study. This article concludes with data from the first examination.
0 1995 by Association of Pediatric Oncology Nurses.

T HE INTEREST IN certification for pediatric

oncology nurses initially evolved from a
roundtable discussion on certification at the an-
pediatric oncology nursing certification
nation.
exami-

nual Association of Pediatric Oncology Nurses Professional Certification

(APON) conference held in 1988. Five years and Brief History of Nursing Certification
many meetings later, certification became a re- Certification is the process by which special-
ality in 1993 when the first national certification ization is recognized by the nursing professi0n.r
examination in pediatric oncology nursing was The American Association of Nurse Anesthetists
administered. This article explains the signifi- began the first nursing certification program in
cance of professional certification, describes the 1946, followed by the American College of Mid-
history of certification in pediatric oncology wives 25 years later (a thorough history of cer-
nursing, and summarizes the results of the first tification is provided by Nelson, 1 989).2 To date,
more than 35 associations or certifying boards
From the Department of Anthropology, University of offer certification and/or recertification in their
Florkia, Gainesville, FL; Center for Cancer and Blood Dts- respective specialties.1~3~4
orders and Infant/Toddler Unit, Children’s Medical Center
of Dallas, Dallas, IX; Childrens Hospital Los Angeles, Los
Angeles, C& Ambulatoy Medical Unit, Pitt County Me- Defining Certification
morial Hospital, ECU School of Medicine, Greenville, NC
and the Department of Pediatric Oncology, Memorial Certification is generally defined as a vofun-
Hospital, Colorado Springs, CO. tar-y process conducted by a professional non-
Address reprint requests to Holly Ann Williams, MN, governmental organization that measures com-
RNC, CPON, 623 S. W. 21 st Ave, Gainesville, FL 32601.
0 1995 by Association of Pediatric Oncology Nurses. petencies of licensed professionals in a specialty
1043-4542~95/1201-0005$03.00/0 area of practice.5-7 One of the underlying as-

18 Journal of Pediatric Oncology Nursing, Vol 12, No 1 (Januay), 1995: pp 18-24

 Certification
sumptions for certification is that it is a process
based on continual professional growth rather
than a static, one-time examination.4 Increased
practice knowledge and skills are recognized by
certification, as contrasted with licensure, which
is primarily concerned with minimum compe-
tence at entry into the profession.’
Significance of Certification
There is value in professional certification on
many levels. First, certification is an important
distinction for consumer protection. It signifies
to the public a commitment to quality nursing
care delivery.77g-1’ Professionally it can enhance
peer recognition, monetary rewards, job mobility
and career advancement, increased autonomy
of practice, greater respect from collaborating
professionals, and a more positive image for
nursing.6p7,10 in some specialty areas, such as
for a pediatric nurse practitioner, certification re-
quirements are also being incorporated into li-
censing for advanced practice on a state-by-
state basis.’
Personally, certification resuks in a sense of
accomplishment and pride. In addition, it indi-
cates a commitment to continued professional
development and clinical practice, and serves as
a stimulation for continuing education.1s677
As certification becomes more prevalent,
there are additional benefits to the profession,
health care organizations, and third-party reim-
bursement agencies. Certification is a method of
self-regulation within the nursing profession.
Standards and expectations for professional
practice are established through certification
and, thus, the image of nursing within the pro-
fession and for society in general is enhanced.r
Organizations are using certification for staff
recruitment and public relations efforts, as well
as a tool for retention of clinical nurses. Job
advertisements seek to recruit certified nurses,
and certification may be used as one factor in
determination of practice privileges.’ Employers
also perceive that the practice of certified nurses
will decrease risk management concerns.6
Certification may also start to play a more
prominent role in third-party reimbursement.
The credentialling process is an accepted mea-
sure of knowledge and expertise. In the current
health care fiscal crisis, payment of health care
dollars is closely monitored. Reimbursement
of Pediatic Oncology Nurses 19
agencies are viewing certification as one indica-
tion that their money is being spent on quality
health care services.6Xg
Clearly certification offers benefits on multiple
levels. Recognizing the benefits of certification
for its membership, APON made a commitment
to pursue certification as a viable option to
strengthen the organization.
Historical Development of the
Certification of Pediatric Oncology Nurses
Task Force on Certification
At the 12th Annual APON Conference, held in
October 1988, a roundtable discussion on cer-
tification was facilitated by Dr Pamela S. Hinds.
Consensus was reached by the participants that
certification was needed for pediatric oncology
nursing in order to acknowledge the high level
of knowledge and skill required for the specialty.
Other recommendations that arose from the
discussion included (1) certification should be
by written examination as the preferred objective
measure of nursing knowledge; however, it was
noted simultaneously that the written examina-
tion would not reveal the totality of the nursing
experience; (2) APON membership and length
of practice should also be criteria for certifica-
tion; and (3) experience rather than educational
preparation would be a criteria. Dr Hinds for-
warded a summary of the discussion to Geor-
gina Bru, then APON President, for consider-
ation by the APON Board of Directors.
APON appointed a task force to explore the
idea of developing a certification examination.
Dr Hinds became the chairperson of the Task
Force, and the members were Robbie Norville,
Patty Rubino, Leslie Wagner, and Karen Wilson.
The task force charges were divided into two
phases. Phase I objectives included (1) review-
ing and summarizing pertinent literature on spe-
cialty certification; (2) surveying APON member-
ship regarding interest in certification; and (3)
initiating contact with other specialty certifica-
tion boards and the committee for the National
Board of Nursing Specialties. The phase II ob-
jective was to solicit proposals from various test
service organizations detailing method, costs,
and a time frame for developing and maintain-
ing a certification program in pediatric oncology
nursing.
Results and Recommendations from the
Task Force
Phase I activities were completed by Decem-
ber 1989. A statement was sent to the APON
Board of Directors which summarized the liter-
ature review, discussed the results of the mem-
bership survey, and assessed the human and
financial commitment entailed to develop and
implement a certification examination program.
The seven-item membership survey regarding
specialty certification was mailed to 1,229 cur-
rent or potential members of APON. Results ob-
tained from the 277 returned surveys (23% re-
sponse rate) indicated that 91% of the returned
membership was moderately to very interested
in specialty certification, and they favored certi-
fication through APON. Certification with a pri-
mary clinical practice focus with elements of
leadership and management components was
recommended. The task force wondered how
reflective a response rate of 23% was of the
membership at large. However, a recommenda-
tion was made to the APON Board of Directors
and then President, Sue Heiney, that further ex-
ploration into the development of a certification
process be pursued.
With unanimous approval, the APON Board
of Directors approved the initiation of phase II of
the task force’s work. Three test service organi-
zations, specializing in certification testing, were
approached and asked to submit proposals. Af-
ter receipt and careful review of all proposals,
the task force unanimously recommended on
May 22, 1991, that the APON Board of Directors
accept the proposal submitted by the National
League for Nursing (NLN) Test Service.
Board Approval for an Ad Hoc Committee
on Certification
The APON Board of Directors accepted the
task force’s recommendations. On July 2, 1991,
Sue Heiney called Dr Hinds to inform her of the
Board of Directors’ decision to support develop-
ment of a certification program for pediatric on-
cology nursing. They also voted to accept the
NLN’s proposal for developing and implement-
ing the process. The task force work was now
completed and an Ad Hoc Committee on Cer-
tification was established by the APON Board of
Directors to oversee the development of all as-
pects of the certification program in conjunction
with the NLN.
Leslie Wagner McMahon was appointed
Chairperson of the Ad Hoc Committee on Cer-
tification and asked to recommend additional
committee members. Additional committee
members were selected from the membership
to represent diverse educational backgrounds,
employment settings, and geographical loca-
tions. The goal in choosing the committee
membership was to bring together a represen-
tative sample of the diverse nursing expertise
which exists in pediatric oncology nursing. Se-
lected committee members consisted of Beth
Frederick Hasenauer, Penny Pennoyer, Holly
Ann Williams, and Karla Wilson.
The next order of business was to recom-
mend a group of 12 APON members to develop
test question items for the examination. kern
writers were interviewed and selected by the
same criteria as were committee members.
The Process Continues: Deadlines are Set
and The Examination Begins to TakeShape
The first meeting of the APON Ad Hoc Com-
mittee on Certification (unless specified, hereaf-
ter referred to as the committee) took place on
October 17, 1991, at the Hyatt Regency Hotel in
Cambridge, MA, the site of the 15th Annual
APON Conference. In attendance with the com-
mittee members were Carol Kingsbury, then Di-
rector of Test Services for the NLN, and some of
the item writers. The item writers for the first
examination were Jeanette Adams, Cheryl
Conatser, Meredith Happ, Patsy McGuire, Rob-
bie Norville, Mary McElwain-Petriccione, Patty
Rubino, Janet Stewart, Mary Waskerwitz, Margie
Gardner Weiman, Karen Wilson, and Scheri
Young.
Dr Kingsbury and Leslie Wagner McMahon
provided an overview of the certification pro-
cess, detailed the responsibilities for the com-
mittee members and item writers, and provided
a time line in order to have the certification ex-
amination ready for October 1993. The commit-
tee adjourned until the next meeting to be held
jointly with the NLN in New York City.
Ad Hoc Committee Work Responsibilities
The committee met again in December 1991
and July 1992 at the NLN headquarters. An-
 Certification of Pediatic
other committee meeting was held in October
1992 at the annual APON conference in Minne-
apolis, MN. During these meetings, various as-
pects of the certification process were estab-
lished. The criteria for the examination were
determined. The fee for the examination was de-
termined after surveying other certification orga-
nizations’ fees. The fee structure also reflected a
reasonable timely payback agreement with the
NLN. An appeal process was defined, marketing
strategies were developed, and long-term and
short-term goals were set. The logo was de-
signed after the committee decided on the ac-
ronym CPON, designating Certified Pediatric
Oncology Nurse. In addition, suggestions were
given to APON proposing necessary educational
materials. Bylaws were written for incorporation
as a certifying corporation, including board
member schedule of term rotations. Preparation
was made for the pilot examination, planned for
October 1992.
Design and Implementation of
the Examination
Phase I of Test Construction. Role
Delineation and Test Specifications
A logical job analysis of pediatric oncology
nursing was developed by the committee, with
assistance from the NLN staff. This analysis
identified the knowledge and skills thought to be
typical or representative of the desired compe-
tence in the specialty area.12 Because of finan-
cial constraints, the initial logical job analysis
was derived from APON’s Scope of Practice
and Outcome Standards of Practice for Pedi-
1 CONTENT 1 NURSING
II I
Physical Psychosocial
Care 25%
30%
FIGURE 1. Test blueprint
for the first pediatric oncol-
ogy nursing certification ex-
amination.
Oncobgg NLUX.S 21
atric Oncology /Yursing.13 The committee of
experts rated the frequency and importance of
activity statements (regarding knowledge, skills,
and abilities) as they related to the practice of
pediatric oncology nursing. These activity state-
ments were coded in accordance to six classifi-
cation codes that were subsequentfy used to de-
velop the CPON blueprint.
Test Blueprint
The test blueprint outlines specifications that
comprehensively detail the specific areas of
knowledge that the examination will cover, as
well as the cognitive level of each item and the
approximate number of items that should be
written for each area.14 The content was sub-
divided as follows for the initial test blueprint
(Fig 1).
Item Writers Begin the Task of Writing
Test Questions
Once the specifications of the examination
were established, the actual writing of the test
questions could begin. Four item-writing ses-
sions were held at the NLN headquarters during
early Spring 1992 to generate approximately
300 items. Each session consisted of three pe-
diatric oncology nurses who were selected pre-
viously by the committee. The NLN Test Service
staff reviewed, edited, and validated the test
items for accuracy of content. In July the certi-
fication committee met with the NLN to review
all 300 questions. Most of the items became the
basis of two experimental versions of the exam-
TASKS
Information Long-term Growth and
re. Disease Survival Development
and a% 12%
Treatment
25%
ination. The pilot test was administered in Oc-
tober 1992.
CPON Test Pilot
During the 1992 Annual APON Conference in
Minneapolis, MN, proud APON members could
be seen wearing a button that proclaimed,
“CPON Test Pilot.” The button indicated that the
wearer was one of 260 people who took the pilot
test on October 8, 1992. There was a strong
show of support for certification as more than
half of the nurses registered for the APON con-
ference took the examination. After the confer-
ence, NLN scored the examinations and item
analysis data received on these questions was
used as a basis for compiling a final version of
the examination. Everyone who volunteered to
take the pilot test helped make the final exami-
nation a reality.
Ad Hoc Committee to Corporation
The Certification Corporation of Pediatric On-
cology Nurses (CCPON) incorporated on Feb-
ruary 1, 1993. The founding board structure was
composed of the following offices and officers:
President (Leslie Wagner McMahon), Vice-
President (Karla Wilson), Secretary (Holly Ann
Williams), Treasurer (Penny Pennoyer), and Di-
rector-at-Large (Beth Frederick Hasenauer). ln-
corporation served to make CCPON a separate
and distinct Board from APON which exists to
oversee all aspects of the certification process.
Establishing a Passing Examination Score
and Accepting a Final Version of the Test
Perhaps the most difficult task that the
CCPON Board faced was setting a passing ex-
amination score and finalizing the first certifica-
tion examination format to be given in Reno, NV,
in 1993. The Board met at the NLN headquar-
ters once again in February 1993 to accomplish
these tasks under the guidance of the NLN Test
Services staff. As Beth Frederick Hasenauer
noted in the June 1993 edition of the APON
Newsletter, this board meeting took “much dis-
cussion and consensus building!” (p. l).15
Hasenauer l5 detailed the process of setting the
passing score and only a summary of the pro-
cess will be repeated here.
The first task was to decide what level of prac-
tice would reflect the knowledge, skills and abil-
ities required of a CPON. The Dreyfus Model, as
described by Benner,16 was used to determine
the level of practice. According to this model,
levels of proficiency ranged from level 1: novice
to level Vzexpert. Proficient (level lV) was chosen
as the level of practice for credentialing as a
CPON. The proficient practice describes some-
one who “perceives situations as wholes, rather
than in terms of aspects, and performance is
guided by maxims. Experience teaches the pro-
ficient nurse what typical events to expect in a
given situation and how to modify plans in re-
sponse to these events” (p. 405).r6
Once the level of practice was determined, a
passing standardized score could be set for the
examination. The Board first reviewed and ac-
cepted the final version of the examination. A
modified Angoff procedure, under the direction
of Dr Julia M. Leahy, was performed to deter-
mine the cut score for passing the examination.
The Angoff procedure used expert judgment
(CCPON Board) to analyze each question to ar-
rive at a passing score.
The Board also voted to report all total scores
on a standard scale. Using a standardized score
would allow for easier future comparison of data
as the number of actual and experimental items
does change from test to test. About 10% to
20% of the test contains items that are not
scored. These items are included to obtain item
analysis data to decide on their inclusion in a
future version.
The Board selected a scale that had a mean
of 100, with a standard deviation of 10, and a
passing score of 95 or better. The passing score
is the percentage of items that an examinee
must get correct, and this passing score is con-
verted to the standard score of 95.
The final test version for the first examination
was comprised of 201 items. Experimental
items included revisions of previously tested
items or new items written by the Board. Finally,
the Board carefully and thoroughly read the test
in its entirety, checking to see that test scenarios
made sense and that the entire examination was
coherent.
First National Certification Examination in
Pediatric Oncology Nursing
The Day Finally Arrives
On October 2 1, 1993, 445 candidates sat for
the first national certification examination in pe-
 Cerfificafion
diatric oncology nursing in Reno, NV. Test result
data in this section are discussed as reported in
the 1993 annual report of the NLN Test Services
to the CCPON Board.” Most of the candidates
were Caucasian (93%) and female (98%). The
examinees demonstrated consistent knowledge
in the areas of leukemias, lymphomas, and cen-
tral nervous system tumors, but performed the
weakest in the area of solid tumors (although
only slightly worse). A total of 68.5% of the ex-
aminees passed the examination.
Summary of Demographic information
About tie Examinees
Most of the candidates reported their geo-
graphic region as the South or the West. The
Midwest candidates had a significantly higher
pass rate than any other region of the country
(x2 = 2.0, P = .028). Eighty-four percent of the
examinees reported less than 20 years experi-
ence as registered nurses (RNs) and the average
number of years of RN experience was 12 years.
The pass rate increased with years of RN expe-
rience until about the 20-year level, at which
point the success rate on the examination lev-
eled off. Experience in pediatric oncology nurs-
ing correlated with improved passing rates. The
average number of years of experience as a pe-
diatric oncology nurse was 8 years.
For the majority of candidates (82%), the
highest educational credential was in nursing:
29% master’s degree, 40% bachelor’s degree,
13% associate degree, and 10% diploma. Can-
didates with master’s degrees in nursing had the
highest pass rate (92%).
The majority of the examinees worked in hos-
pitals (78%); and of these nurses, 55% worked
in pediatric oncology units. The highest pass
rates were found among candidates who iden-
tified their primary role as either clinical nurse
specialist (97%) or educator (91%) although
the number of educators (n = 11) was too small
to make generalizations. The majority of the
sample identified themselves as clinical nurses
(n = 253) and they had a pass rate of 57%.
Examinees’ Evaluations of the Examination
The candidates were given an opportunity to
complete an evaluation tool after the examina-
tion and 450 people chose to do so. The vast
majority of examinees (79% ) considered the ex-
amination to be of appropriate difficulty. When
of Pediatric Oncology Nurses 23
asked how appropriately the certification exam-
ination assessed individual practice, 74% of the
group thought that the examination was appro-
priate, 18% thought that it was not an appropri-
ate assessment, and 8% were undecided.
When asked how the examination would af-
fect their practice as pediatric oncology nurses,
receiving self-satisfaction was cited by the larg-
est majority of respondents (87%). Receiving in-
creased recognition was also seen as a benefit
by more than half of the examinees (56%).
Fourteen percent of the candidates expected in-
creased compensation and 5% mentioned in-
creased likelihood of promotion.
Candidates wrote comments about concerns
of how current topics were, difficulty of exami-
nation, and emphasis on psychosocial and
growth and development. The comments are
considered by the Board for impact on future
revisions.
Conclusions
The road to certification was a long, some-
times tedious, but always a worthwhile process
shared by many individuals in APON and
CCPON. For those of us who were intimately
involved with the process over the years, it was
an extremely challenging task that taught us
many new aspects to being a professional. lt
evolved from a general discussion at a confer-
ence roundtable to a national certification des-
ignation of which we can all be proud. Certifica-
tion serves as one of the best examples of the
power of membership to enact an important
contribution within the parent organization.
Certification in pediatric oncology nursing of-
fers many benefits and rewards. If you did not
certify during the first examination, opportunity
awaits you at the next examination. If you were
unsuccessful in your attempt, review your trou-
blesome areas and try again. Everyone is urged
to consider certification as a step toward profes-
sional growth and development! Certification
recognition is a “win-win” situation for both the
individual and the profession.
Acknowledgment
The authors wish to gratefully acknowledge the
kind assistance of Dr Julia M. Leahy and the anony-
mous reviewers for comments on earlier drafts of this
article.
The section on Historical Development was made
24 Wi&wns
much easier by using a collection of archive letters,
memos, and other correspondence that circulated
among the Task Force members, ApON board mem-
bers, Ad Hoc Committee on Certification, the Certifi-
cation Corporation of Pediatric Oncology Nurses, and
the National League for Nursing Test Services. In ad-
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