The American Board of Nursing Specialties (ABNS) broadly defines accreditation as “a voluntary, self-regulatory process by which governmental, nongovernmental, voluntary associations, or other statutory bodies grant federal recognition to programs or institutions that meet stated quality criteria” (American Board of Nursing Specialties, n.d.). Each type of accreditation is based on the service provided. For example, NOCA’s credentialing body, the National Commission for Certifying Agencies, has accredited the American Nurses Credentialing Center (ANCC) as a certifying body of professional nursing. ANCC accredits universities and professional nursing organizations that offer continuing education contact hours. University schools and colleges of nursing are also accredited by the Commission on Credentialing of Nursing Education (CCNE). One university may be approved and accredited by multiple credentialing organizations examining different functions or standards.

Academic degrees, such as the baccalaureate, master’s, and doctoral degree, are yet another credential awarded for successful completion of a formal educational degree program. When educational measures of a college, such as the curriculum and testing methods, are evaluated by an accreditation body and approved for preparation of nurses, the public has some assurance that its graduates have met reasonable standards for safe practice. In addition, the development of core curriculum for levels of education and specialties of practice committees, such as those developed for advanced practice forensic nurses, promotes program consistency across colleges and helps to facilitate the development of common or standard competencies that can be measured for that specialty. Therefore, academic degree programs teach and promote standards of practice and are subsequently informed by the standards of practice set by nursing organizations.

Regulation is “the mandatory process government agencies grant time-limited permission to an individual to engage in a given profession, after verifying the individual has met predetermined and standardized criteria (experience, education, and examination)” (Durley, 2005, p. 7). Generally permission or license to practice is afforded by the regulatory agency, such as a board of nursing, when a nurse has graduated from an accredited academic program and passed a mandatory written test. The test measures entry level competencies, whether in generalist or advanced practice, to ensure the minimum-essential level for safety and effectiveness using rigorous testing practices for “high stakes” summative evaluation (Epstein, 2007, p. 389). The successful candidate’s name is placed on a registry, which is continuously updated for past and current status. Licensure, which is title protected, is generally renewed at regular periods of time according to legislative directive (National Organization of Competency Assurance, 2006).

Professionals who are granted membership, by application or nomination, into an organization or “academy,” often receive credentials. The membership qualifications range from successful passage of a certifying exam or evidence of extraordinary professional skills, accomplishments, or expertise. The candidate is then entitled membership or in some cases the title of “fellow.” Maintenance of membership is generally contingent upon continued observance of the high standards and expectations of the professional organization.

Clinical privileging, sometimes referred to as credentialing, is used within a healthcare organization or facility to denote a process of procuring, verifying, and analyzing the eligibility and qualifications of the clinician to execute healthcare services. Privileges are also extended to perform (order) specific diagnostic or therapeutic services in providing specific care within well-defined limits within that organization. Privileges are usually based on state practice acts, agency regulations, license, education, training, experience, competence, health status, and judgment (Smolenski, 2005).

Certification is a formal recognition of the specialized knowledge, skills, experience, and, in some cases, personal attributes valued as critical standards of the profession and demonstrated by an individual. Certification is generally voluntary and awarded by nongovernmental entities that grant time-limited recognition and award credentials. Standards for certification should include competency testing, which is “psychometrically sound and legally defensible,” to afford the certificant the greatest professional credibility (Goudreau & Smolenski, 2008). Certification programs include standards, policies, procedures, assessment instruments, and activities identified as necessary by the certification board of directors of that agency. They are also tasked with other decision making, including governance and terms for withdrawal of credentials (National Organization of Competency Assurance, 2006).

Certification and certificates should be differentiated. Certification attests to competence. A certificate can be awarded on completion of a nondegree attendance or curriculum-based educational offering. A certificate is not an academic degree or professional credential. The recipients are not required to demonstrate competence, but the certificate may be used to meet eligibility for certification depending on the criteria set by the certifying body. The National Organization of Competency Assurance has recently published the first standards for certificate programs, which specify the essential requirements for certificate programs and define the ingredient for a high-quality program (National Organization of Competency Assurance, 2009).

In selecting the appropriate tool to measure and predict competence, several factors should be considered. First, credentialing organizations consider the type of assessment to be conducted: formative, summative, or both. Each has a defined level of practice and education. Formative evaluation of an individual generally occurs during the education phase. It provides a snapshot of the student’s current level of understanding and performance and may guide future learning or instructional design. To use it to the fullest advantage, formative assessment methods should provide for an opportunity to adequately appraise the student of their progress while “instilling motivations for continued learning” (Epstein, 2007, p. 388). Summative evaluation generally occurs at the conclusion of the education phase. It makes a more overall judgment of the student’s competence or qualification to advance to higher levels of responsibility or education. Tools for summative assessment must possess high levels of rigor to appropriately determine an individual’s readiness to graduate, enter into professional practice, or become certified in an advanced practice specialty.

Cary and Smolenski (2005) have delineated other questions to ask when selecting a competency measure (Table 51-1).

Finally, strength of the measurement instrument should be considered when making a selection. In determining the strength of a tool, the main factors are reliability, validity, the preparation provided to assessors administering or performing the assessment, and the impact of the instrument on future learning and practice. Reliability is the degree to which the method is stable in measuring the same competency with repeat administration by numerous assessors or, in the case of a written test, with similar forms of administration such as rewording the same question with the same meaning. Two alternate methods for increasing the reliability of an assessment tool are to either limit the number of assessors over an extended period of time or use a large number of assessors over a short period of time then allow enough time between subsequent use of the tool for reevaluation (Cary & Smolenski, 2005, p. 10). Because the degree to which a method of assessment measures what it is intended to measure may vary, establishing the validity of an instrument involves clearly defining what attributes are to be tested. Resources used to establish validity in professional organizations include practice standards, role delineation studies that narrow competency priorities, content experts who validate the application of content and theory, and early test takers who provide feedback on the test experience. In addition, Miller’s pyramid of competence is one attempt to establish a framework for conceptualizing the essential facets of clinical competency and selection of methods that are most valid for measurement. The facets include the knowledge component (knows), applied knowledge (knows how), performance in simulated situations (shows how), and actual performance (does) (Wass, VanderVleuten, Shatzer, & Jones, 2001). In application, the pyramid points the assessor to the appropriate tool for the phase of skill development and gives direction to the learning that needs to occur in moving toward the goal of competent practice (performance). The feedback that candidates receive regarding their current level of competence may positively or negatively affect their future learning and practice, so criteria for selection of measurement items that are shared and validated by test takers can inform future competence building and further validate the instrument. The criterion and standards should also be reviewed in detail with the assessors. The strength of measurement methods, particularly methods that are viewed as qualitative and subjective, will be improved by the development and use of clear grading guidelines and assessors thoroughly trained on the administration and measurement process.

Testing (formerly written examination) evaluates knowledge and the ability to solve problems. Once considered the gold standard of evaluation, questions have been raised regarding its ability to assess attitudes such as ethical treatment of patients or cultural competence, as well as abilities and behaviors in the clinical setting. Currently, testing’s greatest contribution is in the summative high-stakes evaluation such as academic progression, licensing, and certification. This is due to the inherent ability to assess multiple content areas and the ability to use a computer to score a large number of tests in a short period of time with high reliability. The main limitations of testing result from the fact that many tests are “context poor” (Epstein, 2007, p. 390). It is difficult and time consuming to write complex questions in multiple choice, short answer, and matching formats that measure competencies and the ability to transfer that understanding to other clinical situations. Structured essays are well suited for formative or summative evaluation because they allow for more complexity of thought process including demonstration of synthesis of information and integration of assigned literature. Essays can also eliminate the problem of cueing the student found in other item formats. But structured essays take time to grade and like oral examinations depend on clear grading guidelines for validity as well as reliability (Cary & Smolenski, 2005).

Continuing education requirements are found in all arenas of credentialing. It is a commonly held belief that with increased knowledge comes increased levels of performance. And certainly participation in educational opportunities is a demonstration of a professional’s dedication to learning. Therefore, more exposure to new knowledge should create a better understanding of the scientific principles that undergird practice, and it should also promote professionalism overall. However, that is not necessarily true. Although formal educational offerings that feature a testing element have proven to increase knowledge and subsequent performance, there is no strong evidence that knowledge obtained from either attendance at a lecture, electronic offering, or other didactic continuing education offerings results in a change of behavior. However, when content is offered in conjunction with in vivo simulation or hands-on participation, it has a strong correlation with improved competency and is more closely predictive of actual practice.

Observation of clinical behaviors that constitute competent practice can occur directly in simulated or actual patient care settings. There are advantages and disadvantages to both methods of evaluation. Both are prone to error because assessment findings are dependent on a subjective interpretation of one or more assessors. However, both can be used as powerful tools for instruction and development of student capabilities.

Simulation is one form of performance-based evaluation that is growing in popularity and use despite the financial and time expenditures. It asks participants to imagine an actual clinical situation—often created by clinical laboratory settings with real equipment—and then respond to that situation with interventions that demonstrate in vivo competencies. It is perceived to be a valuable formative as well as summative evaluation instrument as long as, in the case of a formative evaluation setting, time is allotted for appropriate feedback. Checklists of target behaviors and multiple raters across multiple cases are all strategies used to increase reliability. Sufficient time for development of the case is considered essential.

The same principles apply when standardized patients are used in “simulated” patient care assessment. Standardized patients are individuals employed to interact with clinicians and facilitate their instruction in performing patient assessment and procedures of care. They are an exceptional resource who, when well prepared with an understanding of the behaviors to be evaluated as well as the standard for success, can participate in the instruction and the evaluation of students. Then, a series of stations can be set up to teach or test clinical competencies. This is known as objective structured clinical examinations (OSCE) and can be used in the same manner for education and evaluation.

Computer and video simulation eliminates the need for synchronous evaluation by multiple assessors. This in turn can greatly reduce the cost of simulated testing. Fero, Witsberger, Wesmiller, Zullo, and Hoffman (2009) demonstrated the use of 10 videotaped vignettes that simulated change in patient status to develop critical thinking skills in 2144 newly hired nurses using the Performance-Based Development System Assessment tool. The research was conducted using Benner’s Novice to Expert Model and results indicated that years of experience was the greatest predictor of competence but that nurses with experience and higher degrees performed the best. Results were used to plan learning experiences to develop critical thinking for the new hires.