Evolving Practices in Recertification: The Competency and Credentialing Institute’s CNOR Credential

By Carissa Homme, PhD, Manager of Test Development and Certification


Alignment of the prestigious CNOR credential with regulatory, consumer, and provider expectations for competent practice is a top priority for the Competency and Credentialing Institute (CCI), as CNOR is the only accredited credentialing program for professional perioperative nurses. When CNOR’s independent accrediting bodies recommended that CCI reassess and improve the CNOR recertification processes, CCI acted. CNOR recertification is transitioning to a new method, and while the rationale is grounded in research on continuous professional development methods that translate to improved patient outcomes, this change affects how over 40,000 CNOR certificants will recertify their professional credential. This article presents the current recertification methods for the CNOR credential, relevant recommendations from CNOR’s accreditation agencies, the future state of recertification, and how CCI is supporting CNOR certificants through this change.


The Competency and Credentialing Institute (CCI), a nonprofit certification leader in the perioperative nursing community, has offered the CNOR credentialing program for more than 35 years. CNOR is not an acronym, but rather the name of the credential. Perioperative nurses across the world seek the CNOR credential to validate their professional competency and demonstrate their personal commitment to the highest standards of patient care in perioperative nursing practice. CNOR is accredited by the National Commission for Certifying Agencies (NCCA) and the American Board for Specialty Nursing Certification (ABSNC). As of 7/1/2018, 43,476 nurses held an active CNOR credential.

While the accomplishment of earning the CNOR credential is realized as soon as a candidate receives a passing score on his or her exam, the credentialing journey does not conclude there. CNOR certified nurses must maintain their credential through recertification every 5 years. Demonstration of continuous professional development (CPD) is a component of CNOR recertification for every certificant. The Institute of Medicine and the American Nurses Association both encourage CPD for lifelong learning and incorporation of evidence-based practice guidelines into everyday nursing practice.1,2

Historically most CNOR certified nurses use contact hours (also called continuing education or “CE” for short) as CPD for recertification. However, CNOR’s accrediting bodies have recommended that the CNOR recertification process shift to a CPD method that does not rely solely on contact hours. The rationale for this change and the CCI’s communication of this change to the perioperative nursing community are discussed below.

The Old Recertification Model

Perioperative nurses’ reliance on contact hours as evidence of CPD stems primarily from tradition and convenience. Multiple surveys of the certification industry found CE to be the most common recertification method in the certification industry.3–5 While it varies by state, contact hours and/or CE units are also the most recurrent requirement for professional nursing license renewal.6 Many workplaces and professional associations (e.g. the Association of periOperative Registered Nurses (AORN)7) offer low cost or free contact hours that can be completed by attending a presentation during the workday or by signing on to a webinar from home. However, not all contact hours are administered by an accredited provider, and unaccredited contact hours are not accepted for CNOR recertification. The most significant disadvantage of contact hours for the professional nurse is limited evidence linking passive learning methods to improved patient care.1 NCCA Standard 22 lists limitations of CE, citing “convenience and cost over need, points-oriented rather than learning-oriented, [and] commercial or sponsorship bias” as examples.8(page 28)

The New Recertification Model

Both NCCA and ABSNC routinely review and update their standards to reflect best practice in the field of certification, keep pace with industry standards, and ensure clarity.8,9 NCCA’s Standard 22, “Maintaining Certification” defines continuing competency as “demonstrating specified levels of knowledge, skills, or ability not only at the time of initial certification but throughout an individual’s professional career.8(page 27) ABSNC, in Standard 13 “Recertification and Continuing Competence,” states “certifying organizations need to periodically reassess the […] recertification process and continue to improve methods of evaluating certificants’ competence.”10(page 29)

In short, CNOR’s accrediting bodies place the responsibility of reviewing and improving recertification processes with the certifying organization (in this case, CCI) and recommend that these processes look beyond the skill level required for initial certification. Given these recommendations , concerns surrounding the effectiveness of contact hours as a CPD method, and CCI’s commitment to meeting stakeholders’ expectations for competent nursing practice, CCI is advancing towards a new, activity-based recertification method for CNOR. Examples of activity-based options for recertification include the following in the graphic below.


While CCI plans on adding activities to this list, and specifics of the new recertification model are still evolving, CCI’s vision is that each eligible activity completed during a candidate’s accrual period will count for a defined number of points. Point limits exist for each category (academic coursework being the exception) to encourage diversity in CPD. CNORs are likely already engaged in or have opportunities to engage in eligible activities listed above as part of their professional practice and personal CPD initiatives. Contact hours may still count toward a portion of the needed points. Once a candidate earns the required number of points, meets all other eligibility requirements (ref:, and enters their recertification year, they may renew their CNOR credential. Currently, both the old (contact hour) and new (points) methods are available as recertification routes for CNOR.

Supporting the CNOR Community

CCI formally debuted the decision to update the CNOR recertification mechanism at the 2018 AORN Global Surgical Conference and Expo, the largest congregation of perioperative nurses in the world (ref: CCI board members and staff delivered multiple educational presentations on this topic to current and potential CNOR certificants during the conference. The primary goals of these presentations and ensuing discussions were as follows:

  • Inform the audience of upcoming changes in advance of implementation.
  • Explain forces driving the change.
  • Share that the timeframe is still being determined and change will be gradual.
  • Encourage current CNORs to begin adapting now to the new points method.
  • Solicit input from the CNOR community on activities that should count for points.
  • Reassure certificants that CCI will actively communicate new information.
  • Connect personally with perioperative nurses to answer questions and hear concerns.

Understandably, this news provoked a wide range of reactions from the perioperative nursing community. Many nurses expressed discontent and voiced concern about their ability to recertify using the updated CNOR recertification method. Others appeared to readily accept the rationale underlying the change and agreed that CE/contact hours alone do not adequately demonstrate CPD. Some nurses appreciated that professional and volunteer activities they currently perform will now count towards their CNOR recertification.

Additional support efforts underway at CCI include formation of a Recertification Committee and construction of a new Learning Management System (LMS). The Recertification Committee is a group of experienced perioperative nurses tasked with reviewing and approving additional activities for incorporation into the new CNOR recertification model. This group will recommend point values for each activity and provide rationale statements linking each activity to improved competency in perioperative nursing. Current guidance and considerations for these decisions can be found in Chapter 9 of “Certification: The ICE Handbook.”5 Finally, CCI’s newly appointed Certification Council will provide oversight through review and approval of recommendations.

The LMS will connect certificants to free CPD activities that fill known gaps in academic nursing programs and encourage certificants to develop personalized CPD plans. With nursing school curricula often lacking content relevant to the perioperative specialty,11 CCI sees value in making perioperative related learning activities readily available to CNOR certificants. CCI also intends to provide self-assessments and reflective learning activities. These exercises, which have well documented benefits in the both the certification5 and healthcare fields,12,13 allow certificants to identify and focus on areas of deficiency in a more structured and objective manner than is afforded by self-selection of CE alone. Collectively these options will complement both eligible activities listed above and CE/contact hours from accredited providers.

In her “Certification: The ICE Handbook” chapter, Dr. Lenora Knapp states “the issue of recertification and the principles underlying the requirements for retesting, continuing education, continuous learning, or continuous professional development remains one of the most challenging for certifiers.”5(page 203) CCI acknowledges that changes in these areas will also be challenging for certificants as the CNOR recertification process develops with guidance from industry standards and the needs of the perioperative nursing profession. CCI is committed to supporting certificants through these upcoming changes and into the future of meaningful, activity-based recertification. Ensuring the CNOR credential continues to represent nursing competency stemming from evidence-based lifelong learning is a worthy disruption to the traditional CE paradigm.


The author wishes to thank Jim Stobinski, PhD, RN, CNOR, CSSM(E), Dawn Whiteside, MSN-Ed, RN-BC, CNOR, RNFA, and Lisa Alikhan for professional insights and support.


  1. Institute of Medicine, Committee on Planning a Continuing Health Care Professional Education Institute, Board on Health Care Services. Redesigning Continuing Education in the Health Professions. Washington, D.C.: National Academies Press; 2010. doi:10.17226/12704.
  2. Fowler MDM, American Nurses Association. Guide to the Code of Ethics for Nurses with Interpretive Statements: Development, Interpretation, and Application.; 2015.
  3. Knapp & Associates International, Inc. Knapp Certification Industry Scan. Princeton, NJ; 2007.
  4. Institute for Credentialing Excellence. Practices and Requirements of Renewal Programs in Professional Licensure and Certification. Washington, D.C.; 2009.
  5. Knapp L, List C. Recertification and Continuing Competency. In: Certification: The ICE Handbook. 2nd ed. Washington, D.C.; 2015:203-217.
  6. Continuing Education Guide. Accessed July 16, 2018.
  7. AORN. CE Included in Membership - Association of periOperative Registered Nurses. Accessed July 16, 2018.
  8. National Commission for Certifying Agencies (NCCA). Standards for the Accreditation of Certification Programs. Institute for Credentialing Excellence; 2014.
  9. Accreditation Board for Specialty Nursing Certifications. Summary of Standards Revisions, June 2017.
  10. Accreditation Board for Specialty Nursing Certifications. Accreditation Standards.; 2015.
  11. Ball K, Doyle D, Oocumma NI. Nursing Shortages in the OR: Solutions for New Models of Education. AORN J. 2015;101(1):115-136. doi:10.1016/j.aorn.2014.03.015.
  12. Silver I, Campbell C, Marlow B, Sargeant J. Self-assessment and continuing professional development: The Canadian perspective: J Contin Educ Health Prof. 2008;28(1):25-31. doi:10.1002/chp.152.
  13. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of Physician Self-assessment Compared With Observed Measures of Competence: A Systematic Review. JAMA. 2006;296(9):1094. doi:10.1001/jama.296.9.1094.
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