Clinical Nutrition Certification Board Articles & Resources

Several reasons have been cited for this decline, including the cost of the examination and related fees, the difficulty of the examination, and a decrease in the amount of time spent in nutrition support practice. The changes in the number of candidates for certification and recertification and the lower passing rates support the need to evaluate the current method of credentialing nutrition support pharmacists.

There is evidence that there is still a need for pharmacists who have skills in nutrition support. In a recent survey of pharmacy practice in acute care settings, it was found that % of respondents reported routinely monitoring patients on their nutrition In the report published by the Institute of Medicine (IOM), To Err Is Human: Building A Safer Health System, recommendations of the Committee on Quality Health Care in America to reduce medical errors were Based on studies showing an unacceptably high incidence of preventable adverse medical events, the committee recommended that performance standards for health professionals focus greater attention on patient safety. Periodic re-examination and relicensing of physicians, nurses, and other key professionals based on both competence and knowledge of safety practices were recommended. It was also recommended that licensing bodies work with certifying and credentialing organizations to develop more effective methods to identify unsafe providers and take action, thereby ensuring patient safety. Professional certification was cited as the current process for evaluating clinical knowledge after licensure. Some programs are now starting to consider assessment of clinical skills in addition to clinical knowledge to assure improved

Healthcare professionals are concerned about what these changes will mean for the requirements for their own practice and licensure. The emergence of board certification, credentialing, and other certification programs is therefore a topic of concern. Healthcare professionals must assess the variety of certification options and decide the value of each of these credentials to their careers, healthcare organizations, and the patients they serve. There is a need to evaluate the current systems of certification and assess the current needs of those individuals who pursue certification.

The objectives of this study are to describe the activities of nutrition support pharmacists, to determine the benefits and barriers to becoming board-certified, and to assess the current system of certification through the BPS.

CLINICAL RELEVANCY

Public concern about patient safety has resulted in recommendations for periodic re-licensing of healthcare professionals and the use of certification programs to evaluate clinical knowledge after licensure to identify unsafe providers. Paradoxically, there has been a decline in the number of pharmacists seeking board certification as nutrition support specialists. To respond to the public interest in assuring safe care by proper assessment of care givers, this study was designed to evaluate the current system of certifying nutrition support pharmacy specialists to identify reasons for the declining interest.

METHODS

Questionnaire Development

A survey instrument was developed and pretested by using procedures suggested by Salant and The instrument draft was pretested in December 1999 with 100 pharmacists whose practice area included nutrition support.

Data Collection

After we pretested and modified the survey instrument, it was sent to a national sample of 500 pharmacists. Survey distribution included members of the ASHP Section on Home Care (n = 250) and pharmacist members of ..N. (n = 250). The original sample was reduced because survey instruments were not sent to members with foreign addresses or membership in both organizations.

Although the selection of pharmacists did not encompass all individuals who practice nutrition support, both groups were selected to include pharmacists whose daily practices emphasize nutrition support care. .. Home Care members were surveyed with the intent of including those pharmacists who work for home health agencies and infusion companies. Pharmacist members of ..N. were selected to provide additional coverage of hospital and home health practices, in addition to extended care and skilled nursing facilities.

Potential respondents received 3 mailings. The first mailing included a letter, a survey instrument, and a postage-paid return envelope. This was followed 1 week later by a reminder and thank you postcard. Three weeks after the initial mailing, the survey was mailed again to all nonrespondents.

Data Analysis

Descriptive statistics were used extensively to analyze questions asked related to nutrition support care and board certification. Data were analyzed using SPSS for Windows, release (SPSS, Chicago, IL).

RESULTS

Fourteen of the 500 surveys were undeliverable (eg, insufficient address), resulting in a total of 486 mailed surveys. During the response period of 12 weeks, 258 surveys were returned for an overall response rate of 53%. Returned surveys were excluded from data analysis if respondents no longer provided nutrition support services. This resulted in a total of 210 usable responses. Not all respondents answered all questions. Therefore, the total number of responses to some questions may not total 210.

Respondent and Practice Setting Characteristics

Demographic data of the survey respondents are presented in Table I. More than 30% of the respondents were either currently or previously board-certified in the area of nutrition support. The majority of respondents (%, n = 194) practice in home healthcare settings, teaching hospitals, and nonteaching hospitals.

The highest professional practice degree obtained by survey respondents was a bachelor's degree in pharmacy (BSPharm; %, n = 97), followed by entry level and postbaccalaureate doctor of pharmacy degree (PharmD; %, n = 87). Approximately 30% of the respondents completed a general, specialized, or an alternative type of residency training program, and 3% completed a fellowship-training program in nutrition support or another specialized area.

Approximately 50% of respondents' practice settings have a multidisciplinary nutrition support team (Appendix A). Almost 90% of these teams included a pharmacist. More than 40% of respondent institutions have a multidisciplinary nutrition support committee, almost 80% of which include a pharmacist as a member (Appendix A).

Nutrition Support Activities

Table II describes nutrition-related activities as a percentage of the total amount of time dedicated to nutrition support. Survey respondents reported spending approximately 30% of their professional time on nutrition support activities. Board-certified respondents spent a significantly higher percentage of time (45%) dedicated to nutrition support than non-boardcertified respondents (24%).

Several components of nutrition support activities were analyzed. A greater percentage of time is spent providing individualized nutrition support care to patients receiving parenteral feeding formulations by board-certified respondents (% +/- %) compared with non-board-certified respondents who took, but did not pass, the examination (% +/- %) and those who have not taken the examination (% +/- 29%). Differences were also found in the amount of time spent on other activities, including compounding parenteral and enteral feeding formulations and supervising the compounding of parenteral feeding formulations.

Respondents were asked to evaluate the value of nutrition support activities in relation to the perceived impact on patient outcomes. Based on a 5-point Likert scale, responses were scaled from "1" = extremely necessary to "5" = extremely unnecessary. Respondents perceived that the nutrition support activities provided were extremely necessary in improving patient outcomes (mean SD, + ). Board-certified respondents attributed more value to their activities than their non-board-certified counterparts (mean +/SD, versus and t , respectively, p

Benefits of Certification

To determine potential benefits of certification, respondents were asked to rate the likelihood of obtaining a particular benefit after becoming board-certified through BPS, based on a 5-point Likert scale (Table III).9 The benefit most likely to be obtained after certification was peer recognition. Other benefits of board certification that were ranked highly included test of competence, increase in personal marketability, and increase in professional status. An increase in professional status was viewed more positively as a benefit by board-certified pharmacists than those who are not board-certified. Benefits that were ranked as being unlikely after board certification included career advancement, job security, and job acquisition as part of stated requirements. Obtaining an increased salary or one-time bonus was viewed as the least likely benefit to be obtained after board certification.

Barriers to Certification

Respondents were asked to rate the likelihood of a particular barrier preventing them from becoming board-certified (Table IV). The barrier that was ranked highest as the cause for not seeking certification was the high cost of the examination. Other highly ranked barriers were the lack of reimbursement by employer and the requirement of recertification by examination every 7 years. The barrier that was ranked as the least likely to prevent an individual from becoming board-certified was nutrition support no longer being practiced.

Assessment of System of Certification

..N. has developed Standards of Practice for healthcare professionals, including nutrition support pharmacists, to promote safe and effective delivery of nutrition support, quality patient care, education, and research in the field of nutrition and metabolic support in all healthcare These standards are divided into subsections or chapters which address these areas (Table V). Respondents were asked to rate the ability of the current examination offered by BPS to assess these areas. Responses for board-certified and non-board-certified pharmacists who have taken the examination were compared. Most respondents felt that the examination adequately assessed all areas of the Standards of Practice. An area that was ranked as needing improvement by board-certified pharmacists was the development and implementation of nutrition care plans. This was consistent across all subgroups. The standard that was ranked as having too much emphasis on the current examination was the area of research.

Approximately 45% of respondents felt there was a need for an alternate method of credentialing besides the examination through BPS (Table VI). Respondents were asked to evaluate certain methods and rank their acceptability. Responses from those respondents who agreed with the need for alternate credentialing were compared with those who did not agree with such a need. (Table VII). Both groups ranked a pharmacist-specific examination through the National Board of Nutrition Support Certification (..C.) of ..N. as the most acceptable method for pharmacist certification if the examination through BPS were not offered. The least acceptable alternative was to reduce the minimum passing score of the current certification examination. Board-certified respondents who agreed with the need for an alternate method of credentialing viewed inclusion of Nutrition Support as an "Added Qualification" under Pharmacotherapy as the second least-acceptable alternative. In contrast, pharmacists who took, but did not pass the certification examination and disagreed with the need for alternate credentialing supported the "Added Qualification" method over the other alternatives.

DISCUSSION

In an effort to obtain an estimate of the practice characteristics of nutrition support pharmacists, the Task Force on Specialty Recognition and Certification of Nutritional Support Pharmacists conducted a national survey of hospital pharmacy departments and home infusion therapy companies in 1986. A random sample of hospitals with at least 100 beds from all 50 states were included, and each survey was addressed to the director of

In this follow-up study, approximately 60% of the specialists surveyed practiced in acute care settings and 28% in home health Also, 44% of those surveyed practiced in home healthcare settings and 49% practiced in acute care settings or teaching and non-teaching hospitals. This suggests a trend of nutrition support toward more home care. As hospital length of stay decreased more patients are being cared for in alternate care settings.

Education and training of nutrition support pharmacists has also changed as determined by the highest professional practice degree they reported (BS in pharmacy versus Doctor of Pharmacy-PharmD). In the 1986 survey, a higher percentage of respondents had BSPharm degrees (~60%) compared with PharmD degrees (~40%).1 This compares with the results of the present survey respondents where 47% had BSPharm degrees and 42% had PharmD degrees. This trend may reflect the adoption of the PharmD degree as the entry level degree in . Colleges of Pharmacy. There is a decreasing trend in the number of individuals seeking board certification who have postgraduate training. In the previous task force survey, approximately 35% of the specialists surveyed had completed a pharmacy residency compared with 18% found in this study. Sixteen percent completed a specialty residency or fellowship-training program in nutrition support in the task force survey compared with 7% completing specialized residencies and 4% completing fellowship-training programs reported in this study. This may indicate that with the rise in the number of pharmacists receiving a PharmD degree, postgraduate training is no longer perceived as being needed to perform specialized functions.

In the original petition for nutrition support certification, the Specialty Council on Nutrition Support Pharmacy Practice had to prove that there was a demand for specialists. One measure of the demand for pharmacists with specialized knowledge and training in nutrition support is the number of hospitals with nutrition support teams with a pharmacist member. The original task force survey indicated that >65% of specialists practice with multidisciplinary nutrition support teams. The same percentage indicated that they were members of a multidisciplinary nutrition support committee. The results of the current survey indicate that there has been a decline in the number of currently active nutrition support teams (%) and committees (%). Pharmacist membership in nutrition support teams is high; 90% in the previous survey compared with approximately 85% in the current survey. This suggests that fewer institutions are likely to have formal nutrition support teams. They may use less formal approaches to nutrition care, including the use of committees, clinical guidelines, and consultant specialists. These findings support a continued need for highly specialized individuals who are able to develop and monitor nutrition support policy or assess patients and their nutritional status independently as consultants.

The amount of professional time spent devoted to nutrition support pharmacy practice has declined. In the initial task force survey, respondents spent approximately 55% of their professional time devoted to nutrition support activities compared with 30% found in the current study. In this survey, board-certified pharmacists reported spending more time providing nutrition support than non-board-certified pharmacists or those who had not taken the examination. In the previous study, it was reported that specialists spent approximately 71% of their total nutrition support-related activities providing individualized care compared with 62% today, and 18% of the total time was spent in managing or supervising nutrition support services compared with approximately 27% today. Almost 85% of the respondents' time reported in the previous task force survey was associated with those activities related to parenteral nutrition. This figure compares with the current percentage of approximately 80% found in the current survey. Approximately 15% of specialists' time was devoted to enteral nutrition compared with 10% today. Although there has been a decrease in the amount of time spent on nutrition support, the composition of the time spent is similar. Pharmacists are given less time dedicated to nutrition support activities, but the percentage of the related activities has not changed very much. This suggests that nutrition support pharmacists are performing similar activities, but for less time each day. There is also the perception by individual pharmacists and institutions that these activities improve patient outcomes and are of value.

The benefits and barriers to board certification have long been topics of discussion within professional organizations. In 1996, McArtor and Rascati9 measured the level of tangible and intangible benefits that board certification brings to pharmacists. They found that among nutrition support board-certified pharmacists, "test of competence" was the most highly ranked reason for becoming board-certified (n = 86, %). The lowest ranked reason was "increase in your acceptance by regulatory agencies" (n = 9, %).9

The purpose of this study was to determine the likelihood of obtaining a particular benefit and to determine what factors prevent individuals from becoming board-certified. Increased salary or one-time bonus was the lowest ranked reason for becoming board-certified. Benefits that were obtained by board-certified respondents were personal satisfaction, peer recognition, and increase in professional status. This indicates that the value of nutrition support specialists may not be recognized within institutions.

The high cost of the examination was the most highly ranked barrier to seeking board certification. The cost to first-time applicants of the examination offered by BPS is $600. The examination is offered once a year at designated testing sites. Choosing an alternate testing date results in an additional cost of $550; $450 for the proctor fee and $150 for the site The examination offered by the ..C. for dietitians and nurses costs $190 for members of ..N. and $250 for non-members. For physicians, the cost is $300 for members and $350 for non-members. Special testing center fees in all cases is $ The Disease State Management (DSM) certification through the National Association of Boards of Pharmacy (NABP) is offered at a fee of $135 for each certification There are differences in fees for the different types of certification examinations, some of which are more expensive than others. Preparation tools, guides, or classes are also barriers that contribute to additional time and costs of becoming certified. An interesting future comparison would be to quantify the perceived cost of professional and personal satisfaction and the actual cost of the examination and preparation to determine cost versus benefit.

The second most likely factor to prevent an individual from seeking board certification was lack of reimbursement by employer followed by the requirement for recertification by examination every 7 years. Employers may not reimburse examination-takers for the cost of the examination because they fail to see the significance of board certification to the organization. The administering body might consider promoting certification as a strategy to reduce medical errors and improve patient safety as recommended by the Committee on Quality of Healthcare in

Examination content was also viewed neutrally among respondents. Most individuals believed that the current examination was adequate. In fact, the majority of the respondents (~55%) supported the current process through BPS for certification.

Several alternate methods of providing credentials for nutrition support pharmacists were included as options in this survey. ..C. is an independent credentialing board established by ..N. to administer certification programs in specialized nutrition This board currently certifies physicians, nurses, and dietitians. One alternative included in the survey was to develop an examination for pharmacists in addition to those that already exist for dietitians, nurses, and physicians. Another alternative is to develop a discipline-independent examination administered by the ..C. to any practitioner regardless of discipline.

NABP offers DSM certification examinations. These examinations are standardized assessment tools designed to measure the knowledge and skills of pharmacists providing disease state management services to patients with asthma, diabetes, and dyslipidemia, and those undergoing anticoagulation Although there is no disease state management examination in the area of nutrition, another alternative method of credentialing would be to develop and offer nutrition support certification through a newly developed DSM examination.

In addition to the certification examination, BPS offers recognition of focused areas within established pharmacy specialties termed "Added Qualifications."13 "Added Qualifications" denotes the demonstration of an enhanced level of training and experience within one segment of a specialty area recognized by the The first petition for "Added Qualifications" was Infectious Disease Pharmacotherapy and was recognized in March 1999. An alternate method for nutrition support certification is inclusion of the area as an "Added Qualification" within the Pharmacotherapy specialty.

If the need for an alternate method of certification is necessary, the alternative that was ranked highest was a pharmacist-specific examination through ..C. of ..N. The ..C. examinations currently offered to dietitians and nurses are viewed as being less rigorous than the BPS certification examination for pharmacists by those who have taken both examinations. Respondents felt that the reduction of the minimum score or the inclusion of Nutrition Support as an "Added Qualification" was less preferable to the current method of certification.

Limitations

As with any survey, nonresponse bias may affect the results. Pharmacists who did not return the survey might have given different responses than those who took the time to complete and return it. Nevertheless our response rate of 53% is substantially higher than other surveys, which may minimize this potential source of bias. As with all surveys, a "history effect" may also have been a limitation, in that respondents were asked to remember certain facts or give recollection of activities, such as examination content or number of patients in which nutrition support was provided, that may have taken place years earlier. There is no way to assess this, and thus, the results must be considered with these limitations in mind.

Conclusions

Certification through the Board of Pharmaceutical Specialties is still the preferred method of credentialing for nutrition support pharmacists. The current decrease in the number of candidates and passing rate for those taking the examination may be a reflection of the evolving changes in current practices of nutrition support. Based on the results of this study, three primary areas may need to be addressed.

The first area involves the current examination fee structure. The cost of the examination was the most highly ranked barrier to board certification. The fee for the BPS examination is higher than other credentialing process that might be viewed as an alternative. The lower "price point" of these processes suggest a need to evaluate the cost of board certification through BPS. The current cost of developing and maintaining the BPS examination must be justified based on the technical elements, such as examination domain and question research, and also the tangible and intangible benefits to certification. Unfortunately, board certification is not consistently used in recruitment, salary structures, or advancement of pharmacists, even though there is a perception and some evidence that board-certified pharmacists improve care and reduce healthcare costs.

The second area to be addressed is determining whether the certification examination actually assesses the current practice of nutrition support pharmacy. There is evidence from this study that the location of patient care, academic background, training of candidates, scope of practice, and time spent in nutrition support activities has changed since the first task force analysis. Pharmacists spend less, but more concentrated, time in nutrition support. This supports the continued need for specialized individuals whose expertise is in nutrition support. This factor supports the need for some form of credentialing in nutrition support, and the information about the changes could be used when determining or evaluating the examination domains, content, and questions. Respondents did not support reducing the passing point of the examination. Survey respondents felt that there needs to be an analysis of what the examination is developed to assess in trained nutrition support pharmacists. Although the recertification through examination requirement is applicable to nutrition support, oncology, and psychiatric pharmacy, it was the second most highly ranked barrier to becoming a board-certified nutrition support pharmacist. If actions, such as reassessment of the current system and re-evaluation of the recertification requirement cannot be taken, survey respondents recognized that other alternatives are available.

A third area to be evaluated is whether there is still a need for specialty recognition in nutrition support pharmacy. O'Neal et al14 reported significant discrepancies between practices recommended by ..N. for the preparation and labeling of parenteral nutrition formulations and actual practice. Thus, an opportunity to improve patient safety by improving the percentage of organizations meeting accepted practice standards is needed. Through this study, the areas that have been assessed include current nutrition support activities of pharmacists, established institutional practices, the perceived and actual benefits and barriers to board certification, and an evaluation of the current certification system and opinions of alternate credentialing. Based on the responses to questions related to these areas and the results of the ASHP survey of pharmacy practice in acute care settings,5 there is still a need for nutrition support pharmacists. Agencies that provide credentials to pharmacists who practice in this area must recognize these changes and evaluate the content of the certification examination requirements, costs, content, and recertification methods.

The initial task force analysis provided academicians, providers of continuing education, postgraduate training preceptors, and other educators information to help them evaluate and plan pharmacy curricula-- related to nutrition support, outcome competencies for specialty residencies, and continuing education The results of this survey should provide the same guidance.

ACKNOWLEDGMENT

A grant was provided for this project by the American Society for Parenteral and Enteral Nutrition (..N.).

REFERENCES

1. Holcombe BJ, Thorn DB, Strausburg MS, et al: Analysis of the practice of nutrition support pharmacy specialists. Pharmacotherapy 15:806-813, 1995

2. The Council on Credentialing in Pharmacy: Credentialing in pharmacy. Am J Health Syst Pharm 58:69-76, 2001

3. Board of Pharmaceutical Services: BPS-over 20 years of service to the public and the pharmacy profession. Available at: http:// .org/BPS/. Accessed May 17, 2000

4. Specialty Council Activities: Pharmacy Specialization 11:1-5, 2001, April

5. Pedersen CA, Schneider PJ, Santell JP, et al: ASHP national survey of pharmacy practice in acute care settings: Monitoring, patient education and wellness. Am J Health Syst Pharm 57:2171-2187, 2000

6. National Institute of Medicine: To Err is Human: Building a Safer Health System. National Academy Press, Washington DC, 1999

7. Gourley DR, Fitzgerald WL, Davis RL: Competency, board certification, credentialing, and specialization: Who benefits? Am J Manag Care 3:795-801, 1997

8. Salant P, Dillman DA: How To Conduct Your Own Survey. John Wiley & Sons, Inc, New York, 1994

9. McArtor JP, Rascati KL: Benefits of certification for pharmacy specialists. J Am Pharm Assoc N536:128-134, 1996

10. American Society for Parenteral and Enteral Nutrition Board of Directors: Standards of Practice: Standards for nutrition support pharmacists. Nutr Clin Pract 14:275-281, 1999

11. National Board of Nutrition Support Certification (..C.): Available at: http: //.org/profdev/. Accessed May 22, 2000

12. National Association of Boards of Pharmacy (NABP): Disease state management. Available at: .net/ competency/dsm. Accessed May 22, 2000

13. Bertin RJ: Added qualifications: A new dimension in pharmacy specialty certification. Ann Pharmacotherap 31:1532-1534, 1997 14. O'Neal BC, Schneider PJ, Pedersen CA, et al: Compliance with

safe practices for preparing parenteral nutrition formulations. Am J Health Syst Pharm 59:264-269, 2002

Ruth P. Ebiasah, PharmD, MS, RPh*^; Philip J. Schneider, MS, RPh, FASHP*; Craig A. Pedersen, PhD, RPh*; Jay M. Mirtallo, MS, RPh^^

From the *College of Pharmacy, The Ohio State University; ^Riverside Methodist Hospital; and ^^The Ohio State University Medical Center, Columbus

Received for publication, September 6, 2001.

Accepted for publication, February 20, 2002.

Correspondence: Philip J. Schneider, Ohio State University, College of Pharmacy, 500 West 12th Avenue, Columbus, OH 43210. Electronic mail may be sent to .