Challenges in the Critical Care Workplace

C ERTIFICATION,
EMPOWERMENT, AND
INTENT TO LEAVE CURRENT
POSITION AND THE
PROFESSION AMONG
CRITICAL CARE NURSES
By 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 Association

C E 1.25 Hours
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following 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 certifi-
cation and retention of staff.
To read this article and take the CE test online,
visit www.ajcconline.org and click “CE Articles
in This Issue.” No CE test fee for AACN members.
of Critical-Care Nurses’ (AACNs’) interest in determining the
value and influence of specialty certification.
Objectives To examine relationships between AACN specialty
certification and empowerment, and, secondarily, to examine
these variables as related to intent to leave the current position
and 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 significantly
among nurses certified by AACN and nurses without such
certification. Additional analyses revealed significant differences
in empowerment related to position, education, salary, ethnicity,
sex, intent to leave the current position, and intent to leave
the profession. Forty-one percent of the participants indicated
intent 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 according
to age, sex, years of experience, ethnicity, educational level, and
certification.
Conclusions The value of specialty certification and the impor-
tance of empowerment among critical care nurses are affirmed.

EBR
Evidence-Based Review on pp 228-229
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 and
identify needed enhancements. (American Journal of Critical
©2010 American Association of Critical-Care Nurses Care. 2010;19:218-229)
doi: 10.4037/ajcc2010442

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T
he study reported here was initiated by the American Association of Critical-Care
Nurses (AACN) and funded by the AACN Certification Corporation. It was a direct
result of AACN’s continued interest in determining the value and influence of certifi-
cation. Also, AACN had the explicit goal of increasing knowledge about certification
from the perspective of the organizations in which critical care nurses are employed.
According to the AACN Certification Corpora-
tion, certification is a process by which a non-
governmental agency validates, on the basis of
predetermined standards, an individual nurse’s
qualification for and knowledge of practice in a
defined functional or clinical area of nursing. AACN
certification validates a nurse’s knowledge in the
specialty area of critical care nursing; certification is
seen as adding personal value by recognizing the
nurse’s competencies. Several types of critical care
certification are offered through AACN. Each of
these requires a specified number of clinical hours
of direct patient care and successful completion of a
certification examination.1
Background
The value of specialty certification has not been
examined extensively in research. Yet considerable
interest has been expressed in the relationship
between certification, nurses’ perceptions of their
work life, and nurses’ subsequent retention.2 This
topic is especially relevant because nurse retention
is a key strategy in addressing the nursing shortage,
and retention of critical care nurses is of particular
interest to hospitals. Critical care nurses are highly
skilled and often difficult and costly to replace.
Of particular interest to the present study are
studies relating the variables of nurses’ perceptions
of empowerment and certification to their intent to
leave their current position or the nursing profession.
Although previous research has linked 2 of these vari-
ables (empowerment and certification), no previous
About the Authors
Joyce J. Fitzpatrick is Elizabeth Brooks Ford Professor of
Nursing and Gregory Graham is a lecturer at Frances
Payne Bolton School of Nursing, Case Western Reserve
University, Cleveland, Ohio. Theresa M. Campo is a nurse
practitioner for Bayfront Emergency Physicians at Shore
Memorial Hospital–Emergency Department, in Somers
Point, 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, Case
Western Reserve University, 10900 Euclid Avenue,
Cleveland, OH 44106-4904 (e-mail: jjf4@case.edu).
www.ajcconline.org
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research has linked all 3 of the variables among a
national sample of specialty-certified nurses. In this
study we were interested in the intent-to-leave vari-
ables as a way of indirectly assessing potential
retention of critical care nurses.
Kanter’s theory of structural power in organiza-
tions, which postulates that employees who have
access to empowerment structures have greater work
effectiveness, has formed the basis
for much of the nursing research on The value of
empowerment.3 The theory of struc-
tural empowerment is organized specialty
with the following constructs: (1)
opportunity structures, defined as
certification has
opportunities for growth, learning, not been examined
and movement within the organiza-
tion, and (2) power structures, extensively.
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 those
who feel empowered and experience increased
autonomy, decreased job stress, lower burnout,
increased job satisfaction, and higher commitment.3
Much of the empowerment literature in nursing
is based on the work of Laschinger and colleagues.
Laschinger4 has applied Kanter’s theoretical model
of power within organizations to an understanding
of nurses’ work environments. In the studies by
Laschinger and colleagues, structural
empowerment has been linked to
several organizational outcomes, The relationship
including job stress, job satisfaction,
organizational commitment, and
between certifica-
patient satisfaction.5-7 Laschinger also tion, nurses’
has joined with colleagues in testing
the Nursing Worklife Model, which perceptions of
links organizational variables to job their work life, and
satisfaction and burnout in nurses.8,9
The present study was designed nurses’ retention is
to extend the work of Piazza and col-
leagues,10 who found differences in
a focus of interest.
empowerment between nationally cer-
tified nurses and nurses who were not certified. That
small study among nurses employed in a community
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3 219
 hospital was the first to demonstrate differences
between certified and noncertified nurses on any vari-
able related to the organization. Yet in the study by
Piazza et al, no effort was made to determine whether
the certified nurses had basic or spe-
No other study cialty certification. Also, Piazza and
colleagues did not assess nurses’
has examined the intent to leave in their study.10 The
relationship intent-to-leave variable was of particu-
lar interest in the present study.
between perceived In a national study of specialty
empowerment, certification, Niebuhr and Biel11
found no differences in intent to
specialty certifi- leave among nurses with specialty
certification and nurses who were
cation, and intent not certified. The study, undertaken
to leave (position by the American Board of Nursing
Specialties, included 11 427 nurses,
or profession). 75% of whom had specialty certifi-
cation. Structural empowerment and
organizational commitment were not assessed;
rather, the focus of the study was on the intrinsic
and extrinsic value of specialty nursing certification.11
In a national study of the work environments of criti-
cal care nurses, Ulrich and colleagues12 reported that
48.4% of the nurses in their study indicated intent
to leave their position in the next 3 years. Yet
almost 75% of these nurses indicated that they
planned 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 a
sample of 1355 registered nurses in west central
Ohio. Certification status was not considered in
that study. The researchers found a significant rela-
tionship between empowerment, intent to leave the
current position, and intent to leave the profession.
Nurses with higher empowerment
A total of 6589 scores were less likely to leave either
the position or the profession.
critical care In summary, although some
nurses responded research has been done relating to
some of the variables of interest in
to a Web-based the present study, no other study
survey. included all 3 variables of interest in
the present study: perceptions of
empowerment, specialty certifica-
tion, and intent to leave (position or profession). In
addition, the other studies of certified nurses have
been focused on specialty certification generally
across a range of specialties or on oncology, periop-
erative, or public health nurses specifically. The
present study is the first national study to examine
specialty certification among certified critical care
220 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3
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nurses, particularly in relation to the dependent
variables of empowerment and intent to leave. It
was expected that both perceptions of structural
empowerment and intent to leave would differ
between critical care nurses with AACN certification
and those without AACN certification. The specific
research questions were as follows: Are there differ-
ences in perceptions of structural empowerment
between AACN-certified nurses and those who are
not AACN certified? Are there differences in intent
to leave (current position and the nursing profes-
sion) between AACN-certified nurses and those
who are not AACN certified?
Methods
Sample
A total of 44 143 AACN members (those who
had e-mail addresses on file) were contacted by
e-mail and invited to participate in a Web-based
survey. The link to the survey was kept open on the
AACN Web site for 4 weeks, at which time it was
determined that, according to a power analysis, the
number of responses was sufficient to answer the
research questions. The total sample of respondents
included 6589 nurses, a 15% response rate. Addi-
tional analyses were conducted among staff nurses;
this subsample of staff nurses consisted of 4268
respondents. Results related to the staff nurse sample
will be reported in a separate article.
Variables and Measures
The Conditions of Work Effectiveness Question-
naire, Revised (CWEQ-II), developed by Laschinger
and colleagues,7 was used to measure nurses’ percep-
tions of empowerment. The questionnaire includes
19 items used to assess perceptions of access to 6
empowerment structures: opportunity, information,
support, resources, informal power, and formal
power. Each of these 6 components forms a subscale
on the CWEQ-II instrument. In scoring the CWEQ-II,
a 5-point Likert-scale is used, with scores ranging
from “none” to “a lot” for each item. The questions
are positively worded, and a higher score indicates a
higher level of structural empowerment. Items are
summed 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 scores
for all 6 components. Structural empowerment scores
range 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 as
low levels of structural empowerment, 14 to 22 as
moderate levels of structural empowerment, and 23
to 30 as high levels of structural empowerment.
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 Table 1
Sample characteristics (N = 6589)
Cronbach reliability coefficients (α) of 0.93 for the Variable Frequency Percentage
CWEQ-II total score and subscale reliabilities from
0.70 to 0.89 have been reported.7 In the present Sex
study, the Cronbach alpha for the CWEQ-II total Female 5929 90.0
Male 660 10.0
score was 0.91. The alpha levels for the subscales
were as follows: opportunity, 0.86; information, Ethnicity
White 5788 87.8
0.91; support, 0.90; resources, 0.78; formal power
Asian 340 5.2
(Job Activity Scale), 0.80; and informal power Hispanic 199 3.0
(Organizational Relationship Scale), 0.75. African American 171 2.6
National certification status was determined Other 51 0.8
from participants’ self-reports. Participants were asked Unknown 40 0.6
about specialty certification through AACN and other Education
national organizations. A checklist of all of the AACN Bachelor’s degree 3341 50.7
certifications was provided, including CCRN (adult, Graduate degree 1785 27.1
Associate’s degree/diploma 1463 22.2
neonatal, pediatric acute), PCCN (progressive care),
CCNS (adult, neonatal, pediatric acute clinical nurse Position
Staff nurse 4268 64.8
specialist), CMC (cardiac medicine), CSC (cardiac
Educator 628 9.5
surgery), ACNPC (acute care nurse practitioner), Manager 526 8.0
and CNML (certified nurse manager and leader). Other 475 7.2
Any one of these certifications would define the Clinical nurse specialist 357 5.4
participant as AACN certified. Status with respect to Nurse practitioner 233 3.5
Director of nursing 102 1.5
other national specialty certifications was assessed
in the same manner; that is, a checklist of the spe- Certification
cialty certifications was made available and the par- AACN 2362 35.8
None 1894 28.7
ticipants indicated which certifications they had.
Both 1322 20.1
Participants who checked any one of the national spe- Other 1011 15.3
cialty certifications listed were included in the
Abbreviation: AACN, American Association of Critical-Care Nurses.
“other certification” group. Nurses who checked both
an AACN certification and another national certifica-
tion were included in the “both certifications” group. ethnicity, and sex. Both t tests and χ2 analysis were
Intent-to-leave variables were determined used to determine differences in nurses’ intent to
through participants’ self-reports. Participants were leave their current position relative to the variables
asked to answer yes or no as to whether they intended of age, sex, ethnicity, and education.
to leave their current position and whether they
intended to leave the nursing profession. If they Results
answered yes to either of the intent-to-leave questions, Sample Characteristics
they were then asked to indicate the time frame for The age for the total sample ranged from 21 to
their intent to leave. 72 years, with a mean age of 44
Additional information that was collected
included key demographic variables of age, sex, edu-
years (SD, 9.94 years). Years of expe- AACN-certified
rience ranged from 0 to 51 years,
cation, and ethnicity. Also, variables related to pro- with a mean of 18 years (SD, 10.63 nurses were less
fessional work life included position and number years). Characteristics for the total
of years in nursing. sample are included in Table 1.
likely to leave their
Frequencies, percentages, means, and standard positions and were
deviations were calculated for the study variables. Certification and Empowerment
Both t tests and 1-way analysis of variance were used For the variable of certification, more empowered
to examine differences in empowerment total and respondents were first divided into 2 than nurses
subscale scores with respect to variables of certifica- groups: those who held AACN certifi-
tion. Chi-square analyses were used to determine cation (those who held AACN certifi- who were not
differences in the intent-to-leave variables between
groups based on certification status. Additional analy-
cation only and those who held
AACN certification plus other certifi-
AACN certified.
ses were undertaken to determine the relationships cation) and those who did not hold
between key background variables and empower- AACN certification (those who held other certifica-
ment, including position of employment, education, tion only or those who held no certification).

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 Table 2
Differences in empowerment (CWEQ-II scores)
based on AACN certification (N = 6589) Respondents were divided into 2 groups for
CWEQ-II score
analysis of the position variable: staff nurses and
non–staff nurses (eg, nurse managers, clinical nurse
CWEQ-II scale Certification n Mean SD t P specialists, nurse practitioners, and educators). A t-test
Total Non-AACN 2905 20.95 3.81 -2.73 .006 analysis of differences between the 2 groups indicated
AACN 3684 21.21 3.81 significant differences in total empowerment scores
Opportunity Non-AACN 2905 4.15 0.78 0.37
and all subscale scores except for the resource sub-
.71
AACN 3684 4.14 0.78 scale score. Staff nurses had lower CWEQ-II total
and subscale scores.
Information Non-AACN 2905 3.43 0.97 -3.40 .001
AACN 3684 3.52 0.97 Respondents were divided into 3 groups for con-
sideration of the education variable: associate’s degree/
Support Non-AACN 2905 3.34 0.94 0.36 .72
AACN 3684 3.33 0.95
diploma (n = 1463), bachelor’s degree (n = 3341), and
graduate degree, which included those who had any
Resource Non-AACN 2905 3.09 0.81 1.03 .33
master’s or doctoral degree (n = 1785). Significant
AACN 3684 3.07 0.81
differences were found in all empowerment scores
Formal power Non-AACN 2905 3.15 0.91 -2.52 .01 in relation to educational level. Participants with grad-
(JAS) AACN 3684 3.21 0.92
uate degrees scored higher on the total CWEQ-II
Informal power Non-AACN 2905 3.78 0.80 -8.01 <.001 and all the subscales except the resource subscale.
(ORS) AACN 3684 3.93 0.76
For ethnicity, respondents were divided into 5
Abbreviations: AACN, American Association of Critical-Care Nurses; CWEQ-II, Con- categories: white, African American, Hispanic, Asian,
ditions of Work Effectiveness Questionnaire, Revised; JAS, Job Activity Scale; ORS, and other. One-way analysis of variance revealed
Organizational Relationship Scale.
significant differences between ethnic groups in total
CWEQ-II scores. The highest total empowerment
AACN-certified nurses and nurses not certified by scores were among Asians (mean, 21.76; SD, 3.76),
AACN had significantly different total scores on the followed by whites (mean, 21.08; SD, 3.80), African
CWEQ-II (t = -2.73, P = .006) and significantly differ- Americans (mean, 21.03; SD, 3.74), Hispanics (mean,
ent scores on the subscales of infor- 20.72; SD, 4.04), and other (mean, 20.16; SD, 5.03).
Forty-one percent mation (t = -3.40, P = .001), formal Scores on most CWEQ-II subscales (except for infor-
power (t=-2.52, P=.01), and informal mation and support subscales) differed significantly
of the critical care power (t=-8.01, P < .001). AACN-certi- between ethnic groups.
nurses indicated fied nurses had higher total scores Total empowerment scores and scores on all
for empowerment and higher scores subscales except for the support and resource sub-
intent to leave their on most of the subscales (Table 2). scales differed significantly between sexes. Women
In order to examine further the had higher total empowerment scores and higher
current position; differences in empowerment related scores on the subscales of opportunity, information,
only 7% intended to certification, the sample was formal power (Job Activity Scale), and informal
divided into 4 groups: AACN certi- power (Organizational Relationship Scale).
to leave the fied, other (certified by an organiza-
profession. tion other than AACN), both Intent to Leave
(AACN and other certification), and For the whole sample, 41.1% indicated their
no certification. These 4 groups dif- intent to leave their current position; 18.4% indi-
fered significantly in total empowerment scores and cated that they would leave their current position
in scores on the subscales of information, resources, within the next year. Only 6.9% indicated an inten-
formal power, and informal power. For all of the tion to leave the nursing profession. Of the respondents
significantly different results, nurses with both intending to leave the profession, the largest per-
AACN and other national certification or AACN cer- centage of the total group (3.3%) intended to leave
tification alone had higher scores than did nurses in in 3 to 5 years (Table 4).
the other 2 groups (Table 3). A significant difference was found in intent to
leave current position between respondents who
Empowerment Scores as Related to Key held AACN certification (AACN certification or AACN
Background Variables plus other certification) and those who did not have
Additional analyses indicated significant differ- AACN certification (other certification or no certifi-
ences related to the background variables of posi- cation) with χ2 analysis (r = 4.70, df = 1, P = .05). Those
tion, education, ethnicity, and sex. participants who held AACN certification were less

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 Table 3
Differences in empowerment (CWEQ-II scores)
according to type of certification (N = 6589)
likely to leave their position. When the 4 certification
groups (AACN only, AACN plus other, other only, CWEQ-II score
and no certification) were compared, intent to leave
CWEQ-II scale Certification n Mean SD t P
position did not differ significantly among the 4
groups (P = .06). Total None 1894 20.85 3.81 4.32 .01
Significant differences (P < .001) were found on AACN 2362 21.14 3.74
total empowerment scores and all subscale scores Other 1011 21.12 3.81
between respondents who intended to leave the cur- Both 1322 21.33 3.93
Total 6589 21.09 3.81
rent position and those who intended to leave the
nursing profession. In all instances, those who did Opportunity None 1894 4.14 0.78 2.05 .11
AACN 2362 4.12 0.77
not intend to leave either the position or the profes-
Other 1011 4.16 0.78
sion had higher empowerment scores (Table 5). Both 1322 4.18 0.79
Nurses who did not intend to leave their position Total 6589 4.14 0.78
were significantly older than nurses who did intend Information None 1894 3.42 0.98 4.33 .01
to leave their position (t = 10.83, P < .001). Years of AACN 2362 3.52 0.96
experience also differed significantly between the 2 Other 1011 3.46 0.94
groups. As the participants’ years of experience Both 1322 3.51 0.98
increased, their intent to leave their current position Total 6589 3.48 0.97
decreased (t = 12.45, P < .001). Chi-square analysis Support None 1894 3.34 0.95 0.59 .63
of the total sample (n = 6589) indicated a significant AACN 2362 3.32 0.93
Other 1011 3.36 0.92
difference between the sexes in intent to leave the
Both 1322 3.36 0.99
current position (r = 13.44, df = 1, P = .01). Of the Total 6589 3.34 0.95
participants who reported intent to leave their cur-
Resource None 1894 3.08 0.80 1.24 .03
rent position, men (47.7%) were more likely to AACN 2362 3.08 0.80
leave than were women (40.3%). Other 1011 3.12 0.81
Intent to leave the current position also differed Both 1322 3.06 0.83
significantly among the 5 ethnic groups according Total 6589 3.08 0.81
to χ2 analysis (r = 26.89, df = 4, P < .001). African Formal power None 1894 3.12 0.90 7.37 <.001
Americans were more likely to leave their position (JAS) AACN 2362 3.18 0.91
than were members of the other 4 ethnic groups. Other 1011 3.22 0.93
Both 1322 3.27 0.94
Chi-square analysis showed a significant differ-
Total 6589 3.18 0.92
ence in intent to leave position related to educa-
tional level (N = 6589, r = 61.45, df = 2, P < .001). Informal power None 1894 3.76 0.81 22.59 <.001
(ORS) AACN 2362 3.92 0.75
Respondents with bachelor’s degrees were more Other 1011 3.80 0.79
likely to leave their position than were respondents Both 1322 3.96 0.79
with any other type of educational preparation. Total 6589 3.86 0.79

Discussion Abbreviations: AACN, American Association of Critical-Care Nurses; CWEQ-II, Con-

ditions of Work Effectiveness Questionnaire, Revised; JAS, Job Activity Scale; ORS,
This study adds to our understanding of specialty Organizational Relationship Scale.
certification in critical care nursing and perceptions
of empowerment. Importantly, the results of the study
support the value of specialty certification. Significant Table 4
differences were found in total empowerment scores Intent to leave current position and
nursing profession (N = 6589)
between AACN-certified nurses and nurses not certi-
fied by AACN. Also, when the certification variable Current position Nursing profession
was examined further, those nurses who held both
Intend to leave Frequency Percentage Frequency Percentage
AACN certification and another national certification
had the highest total empowerment scores. Similar No 3883 58.9 6136 93.1
significant differences in empowerment scores were Yes 2706 41.1 453 6.9
found between certification groups for the subscales In 1-11 months 757 11.5 63 1.0
of information, formal power, and informal power. In the next year 452 6.9 40 0.6
In 1-2 years 516 7.8 61 0.9
That is, AACN-certified nurses had significantly
In 2-3 years 370 5.6 71 1.1
higher scores than did nurses not certified by AACN. In 3-5 years 611 9.3 218 3.3
Those who held both AACN certification and other

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

Current position Nursing profession

CWEQ-II score CWEQ-II score

CWEQ-II scale Intend to leave n Mean SD t n Mean SD t
Total No 3883 22.12 3.53 27.55a 6136 22.23 3.77 10.79a
Yes 2706 19.62 3.72 453 19.24 3.90
Opportunity No 3883 4.29 0.70 18.07a 6136 4.16 0.77 7.39a
Yes 2706 3.94 0.84 453 3.88 0.86
Information No 3883 3.66 0.92 17.31a 6136 3.50 0.96 5.95a
Yes 2706 3.23 0.97 453 3.22 1.01
Support No 3883 3.56 0.89 23.67a 6136 3.37 0.94 9.09a
Yes 2706 3.02 0.93 453 2.95 0.93
Resource No 3883 3.20 0.79 14.33a 6136 3.10 0.80 7.27a
Yes 2706 2.91 0.81 453 2.82 0.85
Formal power (JAS) No 3883 3.41 0.87 25.62a 6136 3.21 0.91 9.83a
Yes 2706 2.85 0.88 453 2.78 0.93
Informal power (ORS) No 3883 4.00 0.73 17.08a 6136 3.88 0.78 7.62a
Yes 2706 3.67 0.82 453 3.59 0.81

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

national certification had higher scores on the for-
mal power and informal power subscales.
The total empowerment scores of the sample of
critical 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 certified
by AACN (mean, 20.95). These scores exceeded the
scores reported in earlier studies conducted by
Laschinger and colleagues in which the highest mean
total CWEQ-II score was 19.6, except
for the studies of nurse managers, in
Critical care nurses which the CWEQ-II scores ranged
were moderately from 20 to 21.14 In a study15 of 75 crit-
ical care nurses conducted in Canada,
empowered. the mean total CWEQ-II empower-
ment score was 17.77. It should be
noted that most of the studies reported by Laschinger
and colleagues were conducted in Canada.14 The study
by Piazza and colleagues10 was based in the United
States and had a mean total empowerment score of
21.28; that study included staff nurses and nurses at
all levels of position (including managers and
advanced practice nurses) in a small community hos-
pital. In a recent study16 among critical care nurses
from 25 intensive care units, Manojlovich and col-
leagues studied perceptions of empowerment as
related to communication between nurses and physi-
cians and selected patient outcomes.
The sample in the present study, consisting of
AACN members who were motivated to respond to
the e-mail communication and complete the online
questionnaire, may reflect a highly involved and
committed group of critical care nurses. Further
noted are the significantly higher levels of total
empowerment and higher subscale scores (except
for the resource subscale score) for those who are
in positions other than staff nurse, compared with
staff nurses. The mean total empowerment score of
those in other positions would be categorized as
high empowerment (range for high empowerment
is from 23 to 30). This finding is consistent with
previous research in which nurses in management
and leadership positions were reported to have higher
levels of empowerment.14
Although no effort was made in the present study
to determine differences in empowerment between
critical care nurses in advanced practice roles, it
should be noted that nurses with any graduate degree
had higher total empowerment scores and scores on
all subscales (except for support, in which baccalau-
reate degree nurses had higher scores) than did nurses
with either baccalaureate or diploma/associate’s
degrees. In future studies, evaluation of the combined
influences of advanced education, position, and
certification in relation to perceptions of empower-
ment should be continued.
Results for the other background variables, sex
and ethnicity, where perceptions of empowerment
differed significantly between groups, also are note-
worthy. Women are the dominant group in nursing

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

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and had significantly higher empowerment scores
than men had. Asian and white nurses had the
highest empowerment scores; these groups also rep-
resent the more dominant ethnic groups in nursing.
Nurses who are members of minority groups may
have 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 of
concern, not only in relation to the financial impli-
cations but most importantly in relation to the
effect on the quality of patient care. Adaptations to
a new institution are costly to the hospital but also
require a reinvestment of energy on the part of the
individual nurse. The learning curve associated with
the change may affect patient care. More than 25%
of nurses indicating intent to leave their current
position said that they intended to leave in the next
year. It is highly likely that they have already begun
the process of leaving.
Nurses who did not intend to leave their current
position were significantly more empowered than
were nurses who intended to leave their position on
all dimensions of empowerment measured by the
CWEQ-II. This finding is consistent with previous
research linking these variables directly or relating
intent to leave with job satisfaction.13,17
Significant differences were found between
nurses who intended to leave their position and
nurses who did not with respect to the background
variables of age (younger nurses were more likely
to leave), education (nurses with graduate degrees
were more likely to leave than were nurses with
baccalaureate degrees or nurses with diplomas/
associate’s degrees), men were more likely to leave,
and members of all ethnic/minority groups were
more 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 nurses
who were not AACN certified. Importantly, in sup-
port of specialty certification for critical care nurses,
those with AACN certification were less likely to leave
their position. Yet when the groups were further
divided and nurses with any type of certification were
compared with nurses with no certification, no sig-
nificant differences were found. This result may be
related to the group of nurses who had other certifi-
cation, including those who have specialty and gen-
eralist certification, not just specialty certification. It
also may be that AACN-certified nurses have a high
level of engagement in their professional organiza-
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tion and that their certification and engagement are
directly related to the work activities in critical care
units. This finding regarding differences in intent to
leave related to AACN specialty certification is differ-
ent from the findings of the national study across
specialty groups. Niebuhr and Biel11 reported that
specialty 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 was
the high percentage (93.1%) of critical care nurses
indicating that they did not intend to
leave the profession. This variable
had not previously been studied in a
Women and Asian
national sample of critical care and white nurses
nurses. In relation to the design of
retention programs for critical care had higher empow-
nurses, it is important to understand erment scores.
that even though a larger percentage
of critical care nurses might want to
leave their current position, they intend to stay in
the profession. Nurse managers and hospital execu-
tives should consider ways to retain the nurses in
their positions, including programs that might allow
them to step back from the highly demanding envi-
ronment for short periods. No effort was made in
the current study to determine reasons for leaving
either the position or the profession. Certainly these
reasons should be investigated in future research,
particularly in order to understand the reasons that
critical care nurses might offer for their intent to
leave the current position but not the profession.
Limitations
This study had several limitations. First, the par-
ticipants were only those critical care nurses for
whom AACN had e-mail addresses
available. Also, nurses who
responded to the survey request Nurses with AACN
might have been those nurses who
are more likely to be certified as well certification were
as those who are more empowered less likely to
compared with the general popula-
tion of critical care nurses. Further, no indicate intent to
effort was made to distinguish
between types of certification other
leave their position.
than in a very general manner by
self-report of the respondents. That is, all AACN types
of certification were included together, and all other
national specialty certifications were included together.
Conclusion
This study adds to the literature on specialty
certification as related to both perceptions of
225
 empowerment and intent to leave. In addition,
and importantly, the results support the findings
of recent research on critical care nurses’ percep-
tions of their work environments in which the
researchers reported that most nurses were very
satisfied with nursing as a career18 and the rela-
tionship between empowerment and retention of
nurses.13 Important additions to the literature are
the findings regarding differences in empower-
ment related to specialty certification. The prepa-
ration and subsequent retention of a highly
qualified and committed specialty nursing work
force is key to high-quality patient care and
smooth functioning of health care organizations.
Certified nurses offer knowledge, experience, and
confidence to the institution.
Nurse administrators and health
Additional care executives have an opportu-
research focused nity to create structures that
reward nurse involvement and par-
on strategies for ticipation within the organization
retention of highly and should encourage professional
development through certification.
qualified critical
care nurses Recommendations for
Future Research
is needed. Ultimately, the goal for
research 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 direct
link between empowerment and nurse retention
must be found.
Some of the additional analyses in the pres-
ent study warrant future extensive examination.
One example is the significant differences in
both empowerment and intent to leave related to
ethnicity. It is important to develop better under-
standings of these dimensions among respon-
dents from underrepresented cultural groups in
nursing. Future research should be focused on
determining why these differences occur.
FINANCIAL DISCLOSURES
This study was funded by the American Association of
Critical-Care Nurses Certification Corporation.
226 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3
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eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Respond to This Article” in either the full-text or
PDF view of the article.
REFERENCES
1. 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: a
review 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 theory
of structural empowerment in organizations. Nurs Admin Q.
1996;20:25-41.
5. Laschinger HKS, Havens DS. Staff nurse work empowerment
and perceived control over nursing practice: conditions for work
effectiveness. J Nurs Adm. 1996;26(9):27-35.
6. Laschinger HKS, Finegan J, Shamian J, Casier S. Organizational
trust and empowerment in restructured healthcare settings: effects
on staff nurse commitment. J Nurs Adm. 2001;30(9):413-425.
7. Laschinger HK, Finegan J, Shamian J. The impact of workplace
empowerment 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 practice
environment 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, Fitzpatrick
JJ. 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 of
workplace empowerment, magnet hospital traits, and mental
health. Dynamics. 2004;15(4):19-23.
16. Manojlovich M, Antonakos CL, Ronis DL. Intensive care units,
communication between nurses and physicians, and patient
outcomes. Am J Crit Care. 2009;18:21-30.
17. Frank-Stromberg M, Ward S, Hughes L, et al. Does certification
status 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 in
Beacon units and Magnet organizations. Crit Care Nurse. 2007;
27(3):68-77.
19. Donahue M, Piazza IM, Quinn Griffin MT, Dykes PC, Fitzpatrick
JJ. The relationship between nurses’ perceptions of empower-
ment and patient satisfaction. Appl Nurs Res. 2008;21(1):2-7.
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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.

1. What is certif ication? 7. Which of the following types of nurses responded in greatest number to this
a. The process of becoming a registered nurse through state licensure survey?
b. A nongovernmental agency validates a nurse’s qualification for and knowledge of a. Staff nurses
practice b. Educators
c. The process of graduating from an accredited baccalaureate program c. Managers
d. The completion of a 12-week orientation class at a hospital’s unit d. Clinical nurse specialists

2. Which of the following is not a reason to retain critical care nurses in their
current 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 retention
b. The researchers’ grant for the study required it
c. To validate the previous study of this variable
d. It is part of a synergistic relationship
4. Which of the following theorists states that employees who have access to
empowerment structures have greater work effectiveness?
a. Nightingale
b. Kanter
c. Browning
d. 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.
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 AACN
b. Certified AACN nurses
c. AACN certified nurses who also had another national certification
d. None of the above
11. The total empowerment score for this sample of critical care nurses was
which of the following?
a. Low c. High
b. 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.

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.
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a
Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Fee: AACN members, $0; nonmembers, $10.50 Passing score: 9 Correct (75%) Synergy CERP: Category C Test writer: Jane Baron, RN, CS, ACNP
Program evaluation Name Member #
Yes No
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Objective 2 was met K K City State ZIP
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Content was relevant to my Country Phone E-mail address
For faster processing, take nursing practice K K
this CE test online at My expectations were met K K RN License #1 State
www.ajcconline.org (“CE This method of CE is effective RN License #2 State
Articles in This Issue”) or for this content K K
mail this entire page to: The level of difficulty of this test was: Payment by: K Visa K M/C K AMEX K Check
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 Evidence-Based Review and Discussion Points
By Ruth Kleinpell, RN, PhD
Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review
and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General
and specific questions such as those outlined in the “Discussion Points” box aid journal club participants in probing the quality
of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications
of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 218-227, consider the questions
and discussion points outlined in the “Discussion Points” box. Visit www.ajcconline.org to discuss the article online.

T
his national survey of 6589 critical care nurses American Association of Critical-Care Nurses
explored the value of specialty certification in (AACN) specialty certification and empowerment
critical care nursing. The descriptive study used as well as intent to leave current work in a nursing
a Web-based survey to examine relationships between position and the nursing profession. Results were
compared between (1) AACN certi-
fied nurses and those who held
Investigator Spotlight AACN and other certifications, and
(2) those without AACN certification.
This feature briefly describes the personal journey and background story of
the EBR article’s lead investigators, discussing the circumstances that led The groups differed significantly
them to undertake the line of inquiry represented in the research article fea- in total empowerment scores. Nurses
tured in this issue. with AACN certification alone or
with both AACN and other national
J oyce Fitzpatrick is the Elizabeth Brooks Ford Professor of Nurs-
ing at the Frances Payne Bolton School of Nursing, Case Western
Reserve University in Cleveland, Ohio, and is an adjunct professor
certification scored significantly
higher. Whereas a large number of
in the Department of Geriatrics, Mount Sinai School of Medicine, participants (n = 2706, 41.1%) indi-
New York, NY. cated they intended to leave their
Fitzpatrick has published more than 300 current position, AACN-certified
works on nursing and health care, focused nurses were significantly less likely
mainly on meaningfulness in life. She said, to report an intent to leave their
“I have been interested in the meaningful- position. Overall, nurses who did
ness of nurses’ worklife and, in particular, not intend to leave either a current
ways in which we can improve the worklife position or the nursing profession
experience.” Also, she has worked with doc-
had higher empowerment scores.
toral students who are now in senior health
care leadership positions and who want to
In addition, a high percentage
Joyce Fitzpatrick enhance the worklife of nurses. “Our ulti- (93.1%) of critical care nurses indi-
mate goal is to link the meaningfulness of cated they did not intend to leave
nurses’ worklife to positive patient outcomes,” said Fitzpatrick. the profession.
Regarding this study, the researchers were pleasantly surprised at The results of the study provide
the positive response to the survey within a very short period of important information about the
time. “We concluded that critical care nurses want to tell their stories value of specialty certification and
about their worklife through research participation,” said Fitzpatrick. the relationship between empower-
The researchers also were surprised about the small percentage ment and retention of nurses.
(6.9%) of respondents who indicated intent to leave the profession.
She noted, “This is very good news. Of course, the concern is about
Information From the
turnover from current position. It behooves hospital nurse leaders to
focus on retention. Such programs will ensure a continued highly
Authors
prepared workforce, and will reduce recruitment costs significantly.” Joyce J. Fitzpatrick, RN, MBA, PhD,
Fitzpatrick concluded, “The link to critical care nursing prac- lead author for the study, said the
tice in our study is direct; we should encourage certification, idea for the study was based on
advanced education, and nurse recognition. There is very little prior research that had been con-
research linking either empowerment or certification to positive ducted by her and another research
patient outcomes, but we must pursue that research in the future.” team. She reported, “We were
approached by AACN Credentialing
Center staff who had read a previ-
©2010 American Association of Critical-Care Nurses ously published work (Piazza et al, 2006) and
doi: 10.4037/ajcc2010885 they asked if we would consider a similar study

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

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among AACN members. We added some variables
(intent to leave position and profession) and sampled
only AACN members.”
In the current study, a total of 44143 AACN mem-
bers were invited to participate, and 6589 responded,
which represented a 15% response rate. When asked
if the response rate was sufficient to make generaliza-
tions from the results, Fitzpatrick explained, “We did
a reminder e-mail to the total potential sample (all
AACN members who had e-mail addresses online).
The response rate provides sufficient power for the
analyses that were undertaken and generalizations to
AACN members can be made.”
Nurse respondents were asked to report their
type of specialty certification through AACN and
other national organizations. Fitzpatrick noted that
specific subcategories of certification were not exam-
ined in the current study, but she said, “we do have
those data and could do that additional analysis.”
Implications for Practice
The study results confirm the value of specialty
certification in critical care and the importance of
empowerment, as those nurses who had specialty
certification reported higher perceptions of empow-
erment and less intent to leave a current nursing
position. Significantly, only a small percent intend to
leave the nursing profession, with those who reported
no intention to leave the profession having higher
empowerment scores.
Fitzpatrick said the study results have several impli-
cations for critical care nursing. “Both certification
and education make a difference in the level of empow-
erment, and we should encourage both advanced edu-
cation and recognition for clinical competence in
order to retain the best nurses in hospitals,” she said.
Fitzpatrick advised readers of AJCC to use infor-
mation from the study to focus on ways to increase
nurse retention. She noted, “Take the next step and
evaluate specific retention programs that have been
initiated, or do the same study in your own hospital
About the Author
Ruth Kleinpell is contributing editor of the Evidence-
Based Review section. She is a professor in the Rush
University College of Nursing, a teacher-practitioner at
the Rush University Medical Center, and a nurse practi-
tioner with Our Lady of the Resurrection Medical Center,
Chicago, Illinois.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3
Downloaded from http://ajcc.aacnjournals.org/ by AACN on March 31, 2019
or health care system to determine if the results are
the same.”
eLetters
Now that you’ve read the EBR article and accompanying
features, discuss them with colleagues. To begin an online
discussion using eLetters, just visit www.ajcconline.org,
select the article in its full-text or PDF form from the table
of contents, and click “Respond to This Article” from the
list on the right side of the screen. All eLetters must be
approved by the journal’s coeditors prior to publication.
Discussion Points
A. Description of the Study
 How did this study explore relationships
between specialty certification in nursing and
nursing retention?
B. Literature Evaluation
 What previous research on specialty certifi-
cation in nursing has been conducted?
 How does this study extend the prior
research that has examined empowerment
and certification?
C. Sample
 How was the sample size for the Web-based
survey obtained?
 What were the total sample size and
response rate?
D. Methods and Design
 How was empowerment specifically measured?
 What other data were collected from the
nurse participants?
E. Results
 What were the results of the study?
 How did AACN-certified respondents differ
from those who had other certifications or no
specialty certification?
 How did those who intended to leave their
position differ from those who reported no
intention to leave?
 What percentage indicated an intention to
leave the nursing profession?
F. Clinical Significance
 What are implications of the study for critical
care practice?
 How does the study support the value of spe-
cialty certification in critical care?
229
Certification, Empowerment, and Intent to Leave Current Position and the Profession
Among Critical Care Nurses
Joyce J. Fitzpatrick, Theresa M. Campo, Gregory Graham and Ramón Lavandero
Am J Crit Care 2010;19 218-226 10.4037/ajcc2010442
©2010 American Association of Critical-Care Nurses
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