Nursing Theses and Capstone Projects Hunt School of Nursing
2012
Assessing a Revised Case Management
Orientation Program for Effectiveness
Tammy S. BrownGardner-Webb University
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Brown, Tammy S., "Assessing a Revised Case Management Orientation Program for Effectiveness" (2012).Nursing Theses and Capstone Projects.Paper 105.
Assessing a Revised Case Management Orientation Program for Effectiveness
By
Tammy S. Brown
A thesis submitted to the faculty of Gardner-Webb University School of Nursing in partial fulfillment of the requirements for the
Degree of Master of Science in Nursing
Boiling Springs 2011-12
Submitted by: Approved by:
___________________ _______________________ Tammy S. Brown, RN, BSN Mary Alice Hodge, RN, PhD
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Assessing a Revised Case Management Orientation Program for Effectiveness Tammy S. Brown
Brown, Tammy S. Assessing a Revised Case Management Orientation Program for Effectiveness
Abstract
A problem noted in the researcher’s facility was that case managers were voicing concerns and dissatisfaction with the orientation program. The study, Assessing a Revised Case Management Orientation Program for Effectiveness was conducted to determine if the revised program was effective in improving the case manager’s
satisfaction and attainment of core competencies. A posttest-only design was selected to compare the previous and revised orientation programs. The setting was a 730 bed acute care facility located in Western North Carolina. The sample included a convenience sample of all case managers who completed the case management orientation program during the study period. The method used to measure completion of the required competencies for the revised orientation program was a Case Management Department Orientation Record and the Case Management Department Orientation Survey was used to measure satisfaction in both groups. All case managers from the revised group
completed the Case Management Department Orientation Record before a Case
Management Orientation Survey was sent to them. The survey results showed improved satisfaction with the revised orientation, with an average Likert scale score of 3.5 to 4.17 compared to the previous group’s average score of 1.86 to 2.89. The findings support the theory and instruments used from the literature. However, due to the small sample size N=15, these findings were limited to the researcher’s facility and are non-generalizable.
Table ofContents
Chapter I: Introduction ... 1
Purpose ... 2
Background and Social Significance ... 2
Conceptual Framework ... 3 Significance to Nursing... 5 Theoretical Assumptions ... 5 Research Question ... 6 Definition of Terms... 6 Case management ... 6 Case manager ... 7 Core competencies ... 7
Case management competency ... 7
Preceptor ... 7
Training and orientation programs ... 7
Chapter II: Review of the Literature ... 9
Orientation and Nursing ... 9
Competency and Benner ... 12
Competency and Nursing ... 14
Competency / Orientation and Care Management ... 16
Chapter III: Method ... 21
Method ... 21
Setting ... 21
Subjects and Sample ... 22
Instruments ... 22
Procedure ... 23
Ethical Considerations ... 24
Data Collection ... 24
Data Analysis ... 24
Chapter IV: Results ... 26
Figure 1 ... 26
Comparison of Previous and Revised Orientation Programs... 26
Table 1 ... 27
Four Open-Ended Questions and Responses ... 27
Significance of the Findings ... 28
Implications for Nursing Practice or Education ... 29
Limitation of the Study ... 30
Recommendations for Future Research ... 30
Importance of the Findings for Nursing ... 30
References ... 32
Appendix A: Conceptual-Theoretical-Empirical Diagram ... 35
Appendix B: Case Management Departmental Orientation Record ... 36
Chapter I: Introduction
Assessing a Revised Case Management Orientation Program for Effectiveness A hospital case management program’s success or failure depends on the education and training that the case manager receives upon accepting the role and the continued education and training offered to maintain a competent and confident practitioner (Daniels & Ramey, 2005). Galt (2000) notes that training and orientation programs are methods used by employers to explain the organization’s personnel, culture, resources, systems, and to provide tools which assist the employee with doing their assigned work and in identifying resources within the organization.
A problem noted in the researcher’s facility, a 730 bed acute care Level II Trauma Center hospital located in Western North Carolina was that case managers were not achieving a baseline level of competency for the role of case manager by the end of the six week orientation period. Case managers were beginning to work independently and were experiencing difficulty with completing functions that should have been included in the six week orientation period. At the particular facility, case managers were voicing concerns and dissatisfaction with the orientation program. The orientation program was preceptor lead and utilized current case managers working within the clinical nursing units as the preceptor.
One resource in the literature specific to hospital case management was Daniels and Ramey’s (2005) book titled, “The Leader’s Guide to Hospital Case Management.” In their book, the authors discuss all areas of hospital case management including staffing, assignments, workflow activities, a day in the life of a hospital case manager, and measurable outcomes that a hospital case management program should deliver.
According to Daniels and Ramey (2005) initial curriculum modules recommended for hospital case managers should include thirty hours of classroom programming, which could be offered over a one week period. The curriculum modules should include didactic modules followed by a one on one preceptor experience with a qualified preceptor (Daniels & Ramey, 2005). Daniel and Ramey (2005) discourage peer preceptors for the initial curriculum modules in efforts to avoid communicating inaccurate information and substandard practices, but instead suggest using educators, and departmental or relevant hospital leadership.
Purpose
The purpose of the research study, Assessing a Revised Case Management
Orientation Program for Effectiveness, was to determine if the revised case management orientation program based on Benner’s (1984; 2001) novice to expert framework was effective in improving the case manager’s satisfaction and attainment of core
competencies during the six week orientation period. The previous program was not effective in assisting the case manager with core competency attainment. This has resulted in dissatisfaction and frustration for the newly hired case managers.
Background and Social Significance
Case managers were voicing concerns and dissatisfaction with the current orientation program and core competencies were not being mastered during the six week orientation period. Henning and Cohen (2008) note that as the nurse transitions from the role of caregiver to case manager, the transition is laden with challenges regardless if the nurse was at the novice or expert level in their previous position. Nurses arrive with varying degrees of knowledge, education, experience, and abilities; these experiences typically
have not prepared them for agency policies, ethical dilemmas and an understanding of a broader scope of healthcare issues (Henning & Cohen, 2008). In efforts to improve the case manager’s orientation, the care management leadership and educators redesigned the six week orientation program to include a combination of didactic and preceptor
experiences that were based on Benner’s (1984; 2001) novice to expert model.
Conceptual Framework
The framework used for the research study, Assessing a Revised Case Management Orientation Program for Effectiveness, was Patricia Benner’s (1984; 2001) application of the Dreyfus model of skill acquisition to nursing. The model outlines five stages of skill acquisition, these include: novice, advanced beginner, competent, proficient and expert (Benner, 1984; 2001).
The novice was described as a beginner that has no experience in the situation they were expected to perform (Benner, 1984; 2001). Novices depend on rules to practice, because they have no experiences to draw conclusions (Benner, 1984; 2001). The advanced beginner has met a minimal level of performance and was able to recognize repeated meaningful situational components found in similar situations and guidelines were useful learning tools in this stage (Benner, 1984; 2001). The competent nurse has been practicing in the area for one to three years and visualizes their actions as long range goals or plans (Benner, 1984; 2001). The competent nurse lacks the speed and flexibility but does have a feeling of mastery and the ability to cope with and manage the demands of clinical nursing (Benner, 1984; 2001). The proficient nurse perceives the entire situation rather than separate parts, and perceives it’s meaning in terms of long range goals. The nurse can now identify when the expected normal picture does not occur
(Benner, 1984; 2001). The expert nurse has a vast background of experience, along with an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of alternative diagnoses and solutions (Benner, 1984; 2001).
The revised case management six week orientation program was based on Benner’s novice to expert framework and the Case Management Society of America (CMSA, 2010) standards of practice for case management. Refer to Appendix A for the Conceptual-Theoretic-Empirical diagram. Case managers entering the position were considered to be between the novice and advanced beginner levels, which is defined as no experience in the situation for the novice and marginally acceptable performance for the advanced beginner (Benner, 1984; 2001). The educators and preceptors were considered to be between the competent and expert level; which was defined as having moderate and specific experience for the competent nurse and moderate and broad
experience for the proficient nurse and extensive, intuitive experience for the expert nurse (Benner, 1984; 2001).
According to Benner (1984; 2001) skill development for the novice should include objective patient conditions and rules and the advanced beginner needs guidelines and prior life experience for recognition to occur. Benner’s (1984; 2001) novice and
advanced beginner’s skill development criteria were included in the revised case manager orientation program components, which include both didactic and preceptor experiences. The advanced beginner’s skill development criteria were included in the various required orientation experiences on the “Case Management Departmental Orientation Record,” (see Appendix B). Upon successful completion of the “Case Management Departmental
Orientation Record” during the six week orientation program, the case manager was considered to be at Benner’s (1984; 2001) advanced beginner level, and as having mastered the core competencies necessary for independent practice.
Significance to Nursing
This was a significant area of study based on research indicating that effective orientation programs yield both clinical and financial benefits to organizations. Hayes and Scott (2007) suggest that successful mentoring of the novice nurse on a one to one basis improves competency, patient safety, and commitment, which can result in
improved retention. Retention favorably impacts an organization’s finances by avoiding the expenses associated with recruitment, orientation, and temporary labor coverage for vacant registered nurse positions (Halfner, Graf, & Sullivan, 2008). Recruitment has been a high priority for human resource departments as well as retaining nurses once they enter the organization since the cost of orientation in some cases may exceed the nurse’s annual salary (Funderburk, 2008).
Theoretical Assumptions
The theoretical assumptions were that the revised case management six week orientation program based on Benner’s (1984; 2001) novice to expert framework would be effective in improving the case manager’s satisfaction and attainment of core
competencies during the six week orientation period. The basis for these assumptions include use of Benner’s framework, which is a proven theory found in the literature for nursing training and education programs, Case Management Society of America (CMSA) 2010 Standards of Practice for Case Management and use of valid instruments found in the literature. The instruments were revised versions of Lott’s (2006) “Nursing Services
Orientation” and an “Orientation Survey” the original instruments were used in a successful revised nursing orientation program. Lott (2006) used the results from the orientation survey to compare the original orientation program to the revised orientation program to measure effectiveness. The expected outcomes of an evidenced based revised orientation program based on proven theory, practice standards and instruments would be improved case manager satisfaction and attainment of core competencies during the six week orientation period.
Research Question
The research study, Assessing a Revised Case Management Orientation Program for Effectiveness was conducted to answer the research question. The research question was formulated to determine if the revised case management orientation program was
effective in improving the case manager’s satisfaction and attainment of core
competencies during the six week orientation period. The research question being asked was, was the revised case management orientation program effective in improving the case manager’s satisfaction with the six week orientation program?
Definition of Terms
Definitions of key terms were provided to describe how the terms were applied in the research study, Assessing a Revised Case Management Orientation Program for Effectiveness.
Case management was defined by the CMSA “… as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through
communication and available resources to promote quality cost effective outcomes” (CMSA Standards of Practice for Case Management, 2010, p.8).
Case manager was defined as a health care professional that has responsibility for coordination of care provided to a group of patients based on a specific diagnosis or need (Powell & Tahan, 2008). Additional responsibilities may include patient and family education, advocacy, managing delays in care, utilization management, transitional care, and outcomes management (Powell & Tahan, 2008).
Core competencies for case managers was described by Daniels and Ramey (2005) as being different for every hospital and based on the organization’s culture. The role may consist of blended characteristics of coordinator, financial manager, problem solver, facilitator, counselor, planning manager, educator, and advocate (Daniels & Ramey, 2005).
Case management competency was defined as a product of professional training, experience, mentorship, and exposure to new information (Powell & Tahan, 2008).
Preceptor was defined as an experienced nurse who facilitates and evaluates
learning in the clinical setting over a specific period of time (Billing & Halstead, 2009).
Training and orientation programs were defined as methods used by employers to explain the organization’s personnel, culture, resources, systems, and to provide tools which assist the employee with doing their assigned work and in identifying resources within the organization (Galt, 2000).
Summary
A problem was identified with the case management orientation program at the researcher’s facility and an evidenced based revised case management orientation
program has been created. In an effort to improve the case manager’s satisfaction and attainment of core competencies the revised orientation program was based on Benner’s (1984; 2001) novice to expert framework and CMSA’s (2010) Standards of Practice for Case Management. The research study, Assessing a Revised Case Management
Orientation Program for Effectiveness was conducted to determine if the revised program was effective in improving the case manager’s satisfaction and attainment of core
Chapter II: Review of the Literature
A comprehensive review of literature was conducted to identify the current body of knowledge related to the research study topic. Through a state of the art literature review, relevant research studies and resources were identified that provide support for conducting the research study, Assessing a Revised Case Management Orientation Program for Effectiveness.
The literature review was conducted using case management, case manager,
competency, orientation and training, Benner and novice nursing as key terms to identify research studies and resources that were related to the research study, Assessing a
Revised Case Management Orientation Program for Effectiveness. The state of the art literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline databases for the period 1950 through 2011. The databases were searched using various combinations of the key terms case management, case manager, competency, orientation and training, Benner and novice nursing. A total of 353 peer reviewed articles, reviews and studies were identified. A total of 15 relevant studies were reviewed and included in the review of literature.
Orientation and Nursing
Dellasega, Gabbay, Durdock and Martinez-King (2009) studied the orientation needs of the experienced versus the novice nurse. The researchers noted that the purpose of the study was to explore whether orientation needs of seasoned nurses are similar or different from novice nurses. The sample size included three experienced nurses who were
beginning new positions in case management. The study was qualitative and methods used for data collection included journaling and focus group evaluations. The results
identified through the analysis revealed three themes: assessing, expectations, realistic appraisal and adjusting (Dellasega et al., 2009). The researchers reported that these themes suggest that experienced nurses’ transition in a fluid manner and that orientation programs for experienced nurses should use specific educational strategies and content to facilitate the nurse’s engagement in a new position. Limitations noted by the researchers include small sample size, and due to the comprehensive documentation and discussion, a therapeutic benefit and bias may have occurred.
The purpose of Wordsworth (2010) study was to determine if the Post Anaesthetic Care Unit (PACU) orientation program meets new nurses’ educational needs and if the program is providing knowledge and skills needed for safe practice. The sample
consisted of eight nurses that completed the PACU orientation within the past year. The study type was quantitative, and descriptive data was obtained through voluntary semi-structured interviews with questionnaires (Wordsworth, 2010). The findings noted by the researcher were that nurses generally perceived themselves as very competent in PACU nursing and having good knowledge in PACU competency. However, the researcher noted that mixed ratings of above and below average knowledge levels was identified. In addition, nurses identified their education needs based on the areas in which they felt a lack of competence and knowledge (Wordsworth, 2010). Limitations identified by the researcher included convenience sample from hospital PACU which was small and not representative of all PACU nurses and the five point Likert scale could lead to response set bias.
Galt (2000) studied the value of training and orientation programs in large medical organizations. The purpose of the researcher’s study was to measure the participant's
perception of how their participation in a training and orientation program led to greater workplace effectiveness and reduced employee turnover. The study was quantitative; and participants were from a random sample of 400 employees at all levels and from all specialties or professional disciplines (Galt, 2000). The method used for data collection was a Scanton Survey. Study results noted by the researcher indicated that training and orientation programs are valuable and provide legitimate returns to employers. Program participants must perceive a direct connection between the training program content and their work assignments (Galt, 2000). The researcher notes that organizations should involve focus groups in curriculum reviews prior to finalization and invest accordingly to obtain a return on investment. No study limitations were noted by the researcher.
The purpose of Schank and Weis’s (2001) study was to examine the professional values of senior baccalaureate nursing students and practicing nurses who were part-time graduate students. A convenience sample of 22 part-time graduate students who were also practicing nurses and 29 undergraduate baccalaureate students participated in the quantitative study (Schank & Weis, 2001). The researchers developed a 44-item Nurses Professional Vales Scale (NPVS) that had a 5 point Likert scale to rate answers. The findings indicated that practicing nurses rated behaviors reflecting values in the American Nurses Association (ANA) Code for Nurses as more important than the student sample which supports the fact that practice contributes to value formation (Schank & Weis, 2001). The researchers state that this finding mirrors Benner's (1984) novice to expert model where practice contributes to the development of a skilled practitioner. No study limitation was noted by the researchers.
The purpose of Lott’s (2006) study was to compare the previous nursing service orientation to the redesigned nursing services orientation to determine if the redesigned nursing orientation provided a more meaningful experience for the new employee and improved the orientee’s satisfaction. The orientation program included interactive didactic sessions with power point presentation and discussion, clinical skill labs, computer training and CPR renewal if needed (Lott, 2006). The sample included a total of 74 orientation surveys completed by orientees from the previous orientation (period May-June 2004) program and orientees from the redesigned orientation program (July-December 2004) (Lott, 2006). The study was quantitative and the data was collected using an orientation survey with 10 questions to be answered using a five point Likert scale and four open-ended questions (Lott, 2006). The researcher notes that the survey results indicated that the orientees from the previous orientation rated an overall satisfaction with the program. However, when comparing the two groups the average scores were higher for the redesigned group. The average results from the previous program ranged from 3.2-4.0 and the average results from the redesigned program ranged from 4.4-4.6 (Lott, 2006). Nurses from the redesigned group rated their readiness and preparedness for safe practice higher with an average score of 4.4 compared to the orientees from the previous program that had an average score of 3.6 (Lott, 2006). No study limitations were noted by the researcher.
Competency and Benner
The purpose of Rischel, Larsen and Jackson’s (2007) study was to explore nurses’ competence as revealed during an admission assessment. The researchers describe a sample size of four nurses; two with less than one year of experience and two with
greater than five years of experience. The study was qualitative and the method used was observations of the admission assessment of twelve patients (Rischel et al., 2007). The results concluded that each nurse has practice patterns that did not correspond to the level of expected competence for their years of experience (Rischel et al., 2007). The
researchers noted that the nurses competence appears to be situational rather than related to levels in the developmental model based on observations of some of the variables where experienced nurses acted as advanced beginners and inexperienced nurses acted as experts. Limitations noted by the researchers included the situation selected; an
admission assessment may differ from other nursing situations due to the interpersonal relationship between the nurse and patient and could expose certain perspectives of competence. Another limitation noted by the researchers was that selection of
participants was based on the premise of Benner’s five stage model and not Bourdieu’s theoretical framework.
The purpose of Meretoja, Isoaho and Leino-Kilpi’s (2004) study was to develop and test the Nurse Competency Scale (NCS) instrument to be used by nurses and managers to assess the nurse competence level. The NCS is a questionnaire that consist of three levels of nursing practice (beginner, advanced beginner and competent) and seven competence categories adapted from Benner (2004) (Meretoja et al., 2004). The researchers describe the development and testing of a nurse competence scale that can assess the level of nurse competence in different hospital work environments. A cluster sample of 498 registered nurses from a variety of nursing units was included in the quantitative study (Meretoja et al., 2004). The method used by the researchers was the Nurse Competency Scale (NCS) questionnaire; which includes a 73 item scale with 7 categories. Results noted by the
researchers were that overall self- assessed scores indicated a high level of competence across categories. The NCS data were normally distributed and the higher the frequency of using specific competencies, the higher the self-assessed level of competence
(Meretoja et al., 2004). The researchers note that the study results provide strong
evidence of the reliability and validity of the NCS. Benner's competency framework was used to define categories of nurse competence and deductive analysis was used to
identify the items to the scale. Benner's framework was useful in defining the scope of clinical nursing practice in the acute care settings; however obtaining broader evidence could expand the definition nurse competence (Meretoja et al., 2004). The researchers noted that sampling limitations to medical and surgical specialties occurred due to the nature of the study and therefore; eliminate the generalizability of the findings.
Competency and Nursing
The purpose of Carcich and Rafti (2007) study was to investigate experienced registered nurses satisfaction with using self-learning modules (SML) versus traditional lecture discussion methods to meet competency goals during the hospital orientation program. The sample size described by the researchers included twenty experienced registered nurses newly hired to an acute care hospital. Ten nurses were put in the lecture discussion group and ten in the self-learning module group. The researchers describe the study as a quantitative experimental after-only research design. The method used was a program evaluation instrument used to measure satisfaction with lecture and or
discussion versus SML modules (Carcich & Rafti, 2007). The results showed that experienced registered nurses were more satisfied with traditional lecture and or
2007). The researchers noted two limitations; the learners preferred teaching method was prevented by randomization and the sample size was small.
The purpose of Meretoja, Leino-Kilpi and Kairs (2004) study was to compare a practicing nurses’ self-assessed level of competence and the frequency of using
competencies in different hospital work environments. The quantitative study contained a sample of 593 nurses from various nursing units. The data collection method used was the Nurse Competency Scale (NCS) questionnaire. The researchers noted that all groups rated their overall competence as good. In the areas of managing situation, diagnostic functions and the helping role they felt the most competent (VAS- means 68-69) and least competence in the ensuring quality category VAS -mean 56) and operating room nurses rated themselves lower in competence and frequency in several of the 7 category areas compared to other groups (Meretoja et al., 2004). Self-assessed competence was rated higher when there was increased frequency in use of the competency. Correlations between age, amount of work experience and self-assessed level of competence were positive (Meretoja et al., 2004). Limitation noted by the researchers were that self assessments can be partially subjective and validity of the instrument was handled by using content experts and a pilot test. Another limitation noted by the researchers was that the empirical data was obtained from Finnish nurses; which may contain cultural and environmental differences and this may limit the results from being generalizable.
The purpose of Meretoja and Leino-Kilpi (2003) study was to explore the agreement between assessments made by nurses and their manager concerning the level of nurse competence and the frequency of using competencies in a hospital setting. The researchers noted a sample of 81 staff nurses and their nurse managers selected from a
variety of nursing units. The data collection method included using the Nurse
Competency Scale (NCS) questionnaire. Findings noted by the researchers’ were that managers rated the nurse's competency higher that the nurse’s self- assessed themselves in all categories except in the helping role and diagnostic function which were rated similar; there were significant differences between the two assessments. The most significant difference was found in the teaching-coaching category (Meretoja & Leino-Kilpi, 2003). Limitations noted by the researches include subjective nature to self
assessment and that nurses in this study may have altered their behavior knowing that the manager would be assessing them. Another limitation noted by the researchers was that the University setting was comprised of Finnish nurses that may represent cultural differences and limit the generalizability of the empirical findings.
Competency / Orientation and Care Management
The purpose of Kneafsey, Long, Reid and Hulme’s (2004) study was to explore how a set of practitioners new to care management coped with the challenges of working with a newly created care management assessment and rehabilitation service. The study was qualitative with a sample size of 165 clients; observational and interview methods were used to explore the workings of the care management process (Kneafsey et al., 2004). The researchers noted that three themes emerged from the data: processes of learning to become a care manager; doing care management and experiences of the role. To learn case management staff need to develop a range of new skills, develop supportive case management processes, develop a new identity and work as an interdisciplinary member (Kneafsey et al., 2004). The researchers noted that doing case management involves working with a small number of patients with complex needs. Experiencing the role
often involves crisis management and problem solving (Kneafsey et al., 2004). A limitation noted by the researchers was that a compare group was not possible because implementation of the rehabilitation link teams (RLT’s) were phased in across the country at the same time with clients who met the eligibility criteria.
Schmitt’s (2006) studied the process of role transition for nurses moving from care giver to the role of case manager. The researcher noted that the study purpose was to determine how these nurses experienced role transition and learned how to function as case managers. The researcher notes a sample of 11 experienced nurses that were going from care giver to case manager. The study type was qualitative and the methods used were interviews and focus group data (Schmitt, 2006). The researcher found that the data revealed that these nurses experience specific tensions that are associated with time-task, interactions and relationships, business culture and objectives and self image and
professional identity. The researcher suggests preparing nurses for these tensions and providing support for them during the transition process may help them identify their learning needs and take advantage of opportunities for professional growth and development; which could expedite their attainment of new case management competencies (Schmitt, 2006). Limitations noted by the researchers include a small convenience sample, which were all women which created a lack of generlizability and assessment for difference by gender.
Tahan, Huber and Downey (2006) studied the roles and functions of case managers to identify current practice. The researchers noted the purpose of the study was to
validate the current case management certification exam for relevancy to current practice. The non randomized sample consisted of 6,340; the sample included certified and
non-certified case managers. The study type was quantitative and the method used for data collection was the practice analysis survey (Tahan et al., 2006). The results identified 6 new functions and knowledge areas that describe case management practice. Research finding benefits noted by the researchers include identification and validation of the roles, functions, activities, and knowledge areas useful for standardizing case management practice, state-of-the-art educational and training programs, and skills and competencies needed for performance and outcomes. No study limitations were noted by the
researchers.
The purpose of O’Donnell’s (2007) study was to describe the experiences of ethical concerns by clinical nurses as they transition to their new role of case manager. The study was qualitative and used an interpretive phenomenological approach, where the 15 participants were interviewed to obtain descriptive data (O’Donnell, 2007). The
researcher notes that insights from the interview analysis have implications for nursing practice, ethic and research and recommendations for organizations for case management recruitment, orientation, training and continued need for educational support were
identified. Limitation included a small sample from one facility which limits the generalizability of the results (O’Donnell, 2007).
The purpose of O’Donnell’s (2007) study was to describe ethical concerning experiences of case managers as they transition from clinical nurse to the case manager role. The researcher describes a sample of 15 nurses from an acute care military not-for-profit community and teaching hospital. The study was qualitative and the data
collection method included interviews that used an interpretative phenomenological approach (O’Donnell, 2007). The researcher reported that the results identified
implication for nurse case management practice including: clinical decisions in daily case management practice represented challenges to the nurses. Adequate education to the case management role is critical for the beginning case manager (O’Donnell, 2007). The researcher notes that case managers need to be aware that a mismatch between their obligations to the organizational goals and the health care needs of their patients may occur. In addition, to linking patient care outcomes with accountability; case managers may need to advocate policy changes and system reform (O’Donnell, 2007). Limitations noted by the researcher include results that were limited to the experiences of 15
participants and that other ethical concern may be identified by other groups. Geographic location of the study was limited to the mid-Atlantic region of the United States; cultures may differ in different parts of the country (O’Donnell, 2007). Other healthcare settings such as emergency department, outpatient, skilled nursing facility, ambulatory care, hospice, and so forth may produce different results (O’Donnell, 2007).
Summary
The literature review identified relevant research studies and resources related to the research study. Benner’s novice to expert framework was supported by Schank and Weis’s (2001) study where practice facilitates skill acquisition and competency. Case management specific orientation and education was supported in the literature with O’Donnell’s (2007) study where adequate education to the case management role was noted to be critical for the beginning case manager. One relevant study supported comparing a previous nursing orientation program to a revised nursing orientation
program to measure the revised program’s effectiveness (Lott, 2006). The relevant study that compared a previous orientation program to a revised program was limited to nursing
services orientation, rather than case management specific orientation. In addition, the study was conducted at a specific facility; therefore, the results were not generalizable to the case management orientation program at the researcher’s facility.
Although relevant studies and resources support the research study, gaps in the knowledge relevant to orientation program comparisons of a previous orientation program to a revised program specific to case management orientation exists. The research study would determine if the revised case management orientation program was effective in improving the case manager’s satisfaction and attainment of core
Chapter III: Method
A detailed description of the method, setting, subjects and sample, instruments, procedures, ethical considerations, data collection and data analysis for the research study, Assessing a Revised Case Management Orientation Program for Effectiveness were selected to answer the research question. A quantitative method with a posttest-only design was selected to compare the previous orientation program to the revised orientation program. An orientation record and an orientation survey were used to capture data to determine the program’s effectiveness and the participant’s satisfaction.
Method
The research study, Assessing a Revised Case Management Orientation Program was a quantitative study. A posttest-only design with a comparison group was appropriate to assess the revised case management program’s effectiveness by comparing the revised orientation program to the previous orientation program. The method used to measure completion of the required competencies for the revised orientation program was a Case Management Department Orientation Record and the Case Management Department Orientation Survey was used to measure the case manager’s satisfaction with the orientation program.
Setting
The setting for the study, Assessing a Revised Case Management Orientation Program for Effectiveness was a 730 bed acute care Level II Trauma Center located in Western North Carolina. This facility is a regional referral center for Western North Carolina and the surrounding regions. The facility is credentialed as an accredited chest pain center, and joint commission certified stroke center hospital. This facility employs a
monthly average of 2,263 registered nurses and has an average daily census of five hundred and eighty acute care patients.
Subjects and Sample
A convenience sample of all case managers who completed the case management orientation program at the facility during the period September 1, 2010 – November 10, 2011 were included in the study. All case managers who complete orientation during this period and that are able to read, write and speak English met the inclusion criteria. The exclusion criteria included case managers who completed orientation before or after September 1, 2010 – November 10, 2011.
Instruments
The instruments were revised versions of Lott’s (2006) “Nursing Service
Orientation” and “Orientation Survey,” the original instruments were used in a successful revised nursing orientation program. The researcher obtained permission (Appendix C) to use the instruments by sending a request to Ms. Lott through electronic mail. The Case Management Department Orientation Record was used for the revised case management orientation program. This instrument was a revised version of the previous case
management orientation record and was based on Lott’s (2006) Nursing Service Orientation. The Case Management Department Orientation Record (see Appendix B) was revised to include essential case management core competencies to ensure an effective orientation.
The orientee’s satisfaction with both the previous and revised orientation programs was measured using the Case Management Department Orientation Survey, (see Appendix C), which was a modified version of Lott’s (2006) Orientation Survey. The
survey contained a demographic section developed by the researcher to measure the subject’s title and credentials, education, years of experience in nursing and case management using a range of years and employment status of full-time, part-time or as needed. A statement at the top of the demographic section requested that the
demographic information be completed without any names or identifying information. The demographic section was later removed from the survey to protect the participant’s confidentiality. The survey contained 10 questions that were answered using a five point Likert scale ranging from 1 (very poor) to 5 (excellent) and four open-ended questions. To differentiate the surveys for the two groups, the researcher placed a footnote at the bottom of the survey, “orientation before 9/2011” for the previous orientation group and “after 9/2011” for the revised orientation group. The survey was reviewed by the management and education team and tested by these individuals for content validity.
Procedure
The Case Management Department Orientation Record was concurrently filled out as the case manager completed the items during the six week orientation period. The case managers’ satisfaction with the orientation program was measured using the Case
Management Department Orientation Survey. An electronic copy of the survey was sent to the case manager upon completion of the Case Management Department Orientation Record and completion of the orientation period for the revised orientation group. The case managers who completed the previous orientation program also received an electronic copy of the case management department orientation survey. Both groups were instructed to print the survey and complete it within one week with no identifying
information on the survey. The completed paper survey was returned to the educator through inner office mail which protected the participant’s identify and confidentiality.
Ethical Considerations
The ethical considerations for the study, Assessing a Revised Case Management Orientation Program for Effectiveness, included self determination, privacy, Institutional Review Board (IRB) review and the right to anonymity. Participation was voluntary; the case manager could either complete the survey or decide not to complete the survey without any concerns for repercussions. The researcher requested an expedited IRB review and approval from the university and the research facility’s IRB. The completed surveys did not contain any identifying information therefore, the participant’s privacy and right to anonymity was protected. The completed surveys were stored in a locked file in the researcher’s office at the facility.
Data Collection
The data was collected with the case management department orientation survey. The survey was sent to all case managers that completed orientation during the period September 1, 2010 through November 10, 2011. The case manager received the survey through electronic mail with instructions to print the survey and return the paper survey to the educator through inner office mail in order to maintain the participant’s
confidentiality. Data Analysis
The data from the previous and revised orientation participant’s surveys were entered into Microsoft Excel on the researcher’s computer and summarized for result reporting. The demographic data would be summarized and reported according to the demographic
categories on the survey: title and credentials, education, certifications, years of nursing experience, years of case manager experience, and employment status. Individual scores for each of the 10 questions on the survey were entered into excel and an average score for each of the 10 questions was calculated for the previous orientation program and compared to the revised orientation program. A two dimensional line chart from Microsoft Excel was used to illustrate the average score per question from the previous orientation program and the revised orientation program. The answers from the four open-ended questions were entered into Microsoft Excel and summarized and reported according to frequency reported by the previous orientation program and the revised orientation program.
Summary
The method, setting, subjects and sample, instruments, procedures, ethical
considerations, data collection and data analysis for the study, Assessing a Revised Case Management Orientation Program for Effectiveness were identified and discussed. The study was a quantitative study that took place in the facility where the researcher is employed. The sample included all case managers that participated in the facility’s orientation program during the past fourteen months. Instruments were obtained from the literature and the data was collected using the orientation survey. The research question was answered through data analysis and comparison of the participant’s satisfaction with the previous and revised orientation programs.
Chapter IV: Results
The sample included all case managers who completed the case management orientation program at the facility during the period September 1, 2010 – November 10, 2011. The original survey was modified to exclude the demographic section as
recommended by the university’s Institutional Review Board to protect the identity of the expected small sample size of 15-30 participants.
A total of nine case managers qualified to participate in the previous orientation group. None of the case managers declined; the return rate was one hundred percent. The revised orientation group also had nine case managers that qualified to participate. Three declined; and the return rate was sixty seven percent. A comparison of the average score for each of the ten questions answered with the five point Likert scale for the previous and revised orientation programs were summarized in Figure 1.
Figure 1
Comparison of Previous and Revised Orientation Programs
Survey Instrument is a revised version of Lott’s (2006) Nursing Orientation Survey used with permission.
0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 1 2 3 4 5 6 7 8 9 10 A v e r a g e Question Average Before N=9 Average After N=6
A total of three participants from the previous orientation group and four the revised orientation group responded to the four open-ended questions. The four open ended questions and the participant’s responses were summarized in Table 1.
Table 1
Four Open-Ended Questions and Responses
Question Response
1. What scheduling changes can be made to improve the orientation week?
2. What else would have been beneficial to review with you during your case management orientation?
3. What specifically can be done to improve the case management orientation? 4. What specifically can be done to improve your unit orientation?
Previous Orientation Group
1 “As needed case manager back-up to solve unexpected problems as they arise; time for orientee
and preceptor to focus on objectives.”
2,3,4 “More orientation time with a social worker outside of assigned unit”
2,3,4 “Develop a systematic process to introduce case management basics. Formal classes for Midas,insurance and case scenarios. Single most important factor in my opinion is to have the department collectively on the same page with documentation, processes and
InterQual®.”
3 “Goals; more structure.” Revised Orientation Group
1 “I have no issues with the schedule”
1 “Shorter time period with Utilization Review; it is good to develop a relationship but four hours is a little much.”
2 “Incorporate the learning skills manual into the orientation to allow for group review and an opportunity to ask questions.”
2 “Would have liked to see the preceptor book made into a couple of days of class to allow discussion
and question opportunities.”
2 “It would be helpful to have an InterQual® refresher class after being on the floor for awhile.” 3 “Better organization; but my group was the test group.”
3, 4 “There should have been a discharge planning day where core issues (like guardianship) would be reviewed. It was difficult for the discharge planners to find time while covering a full case load on the units.”
4 “More time understanding the structure of doctors (Asheville Cardiology, Physician Assistants and Attending, etc.).” Survey Instrument is a revised version of Lott’s (2006) Nursing Orientation Survey used with permission.
Chapter V: Discussion
The study, Assessing a Revised Case Management Orientation Program for
Effectiveness was conducted to determine if a revised case management program based on Patricia Benner’s (1984; 2001) novice to expert conceptual framework was effective in improving the case manager’s satisfaction with the six week orientation program. The instruments were from the literature and revised versions of Lott’s (2006) Nursing
Orientation Record and Nursing Orientation Survey. The study results support the use of Benner’s theory in providing an orientation program that was effective in improving the case manager’s satisfaction and attainment of core competencies during the six week orientation program at the researcher’s facility.
Significance of the Findings
The findings from the study, Assessing a Revised Case Management Orientation Program for Effectiveness support Benner’s (1984; 2001) novice to expert conceptual framework used in the revised orientation program. The case manager’s received didactic and preceptor experiences with qualified instructors and preceptors. All case managers that attended the revised case management orientation program completed the novice and advanced skill development criteria. This criterion was included in the revised case management program components and included both didactic and preceptor experiences. All case managers completed the Case Management Orientation Record that included the core competencies for case management before a Case Management Orientation Survey was sent to them. Results from the Case Management Orientation Survey showed improved satisfaction with the revised orientation when compared to the previous orientation program. The revised group’s average score for the ten questions
answered with the five point Likert scale ranged from a low score of 3.5 and a high score of 4.17 compared to the previous orientation group’s average low score of 1.86 and a high score of 2.89.
The four open ended questions were answered with suggestions to improve the orientation program. Comments were received from three of the previous group
participant’s and included consistent processes for all case managers, formal classes and training for case management basics, “back-up case managers to assist with unexpected problems,” and “time for preceptor and orientee to focus on objectives.” Comments were received from four of the revised group participant’s and included better
organization, more class room time to allow for group review and discussion, less time with a peer group, additional time in discharge planning training and a review of physician structure.
Implications for Nursing Practice or Education
The implications for nursing practice and education include continued support for using the conceptual framework and instruments used in Assessing a Revised Case Management Orientation Program for Effectiveness. The results support using Benner’s (1984; 2001) novice to expert conceptual framework for nursing training and education. All case managers from the revised group completed the Case Manager Orientation Record and completed the core case manager competencies during orientation. The revised versions of Lott’s (2006) instruments were found to be effective in ensuring that program components were completed during orientation and to measure the participant’s satisfaction with the orientation program.
Limitation of the Study
Limitations for the study, Assessing a Revised Case Management Orientation
Program for Effectiveness include a small sample size and non-generalizable results. The sample size consisted of 15 participants, nine in the previous orientation group and six in the revised orientation group. The sample size was limited due to time frames needed to complete the study and the number of new case managers hired during the study period. The results do not reflect a statistically valid sample and therefore cannot be generalized to other facilities.
Recommendations for Future Research
Recommendations for future research include replicating this study for an expanded period of time to obtain a larger sample size that would be statistically significant or conducting the study in a facility that employs a larger number of case managers. A statistically significant sample would yield generalizable results that would validate the effectiveness that the program would have in other facilities. These studies would contribute to the literature, case management specific orientation program comparisons that include nursing theory, education and research.
Importance of the Findings for Nursing
The importance of the findings for nursing include knowledge that a revised case management orientation program supports the use of Benner’s (1984; 2001) novice to expert conceptual framework for nursing training and education. In addition, the revised versions of Lott’s (2006) instruments were found to be effective in ensuring program components were completed during orientation and to measure the participant’s
satisfaction with the orientation program. These findings provide support for the theory and instruments used in the revised case management program at the researcher’s facility.
Summary
The findings from the study, Assessing a Revised Case Management Orientation Program for Effectiveness support the theory and instruments used from the literature. The revised instruments were found to be effective in ensuring that program components were completed during orientation and to measure the participant’s satisfaction with the orientation program. However, these findings were limited to the researcher’s facility and were not generalizable. Further research is needed to support the theory and
instruments for use in future studies. This research would add to the body of knowledge for case management orientation program comparisons that include nursing theory, education and research.
References
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Appendix A: Conceptual-Theoretical-Empirical Diagram
Conceptual Model Benner’s (1984; 2001) Novice to Expert Framework Conceptual Model
Concepts Novice-Advanced Beginner Case Manager Orientee
Competent – Expert Educators / Preceptors
Theory Skill Acquisition
Orientation Didactic & Preceptor
Qualified Educators and Preceptors Empirical Research
Concepts
Orientation Check List and Orientation Survey
Orientation Check List and Orientation Survey
Appendix B: Case Management Departmental Orientation Record NAME/TITLE: _________________________ DATE OF HIRE:______________________
NEW HIRE/TRANSFER/TEMP ID#________________ UNIT:_________ PRECEPTOR (S)_______________ DATE ATTENDED GENERAL HOSPITAL ORIENTATION: (new hires)________________
This checklist is to be completed within six weeks of employment or transfer to ensure the new staff member has been properly oriented
Department Orientation Initials/Date Department Orientation Initials/Date
Meet Manager/Unit Supervisor/Manager
Review Orientation Agenda
Work schedule Sick/Call in line
PTO/OT/Holiday Scheduling (see Attendance/PTO/OT policy)
Dress appearance (see Professional Image policy)
Computer ID/Password Long Distance Code
Organization Structure/Support Services
Telephone/pager use (see Nortel User Guide)
RN/SW License on file BLS card copied/filed (or scheduled)
Role description (signed for file) and Performance Evaluations
Monthly Staff meetings/General Office Communication Policies/Procedures: Care Management Infection Control Safety HR Hospital Administrative Nursing Administrative Department Specific: MOD –resources Core Measures Continuing Education Gifts/Solicitations/Vendors Abuse-ID and Management Abuse Statistic Data Collection
Confidentiality Policy (signed for file) Conflict of Conscience Policy (signed for file)
Location of Safety, MDS, Infection – Departmental policy manuals
Added to E-mail distribution lists
Access/using:
____E-mail (profile update) ____Citrix
____Cerner (Power Chart) ____Cerner PM
____Midas ____Kronos
Access/using:
____Web In Service (WIS) ____Internet
____Report an event ____Tube system
____ Unit Fax machine / long distance ____ Unit copier
Core Competencies Initials/Date Checklists/Certifications Initials/Date
Core Skills for Case Managers Case Management Certification
Admission Case Manager Orientee Evaluation Form
Learning Modules Initials/Date Classes Initials/Date
Web based Midas module Teach Back
Core Measures UR/OBS *Initials/Date indicates successful
completion of an item.
Cerner Power Chart Class
__________________________________ _________ ________________________________ ______
Appendix C: Case Management Orientation Survey
Please complete the survey and answer the questions listed below without any names or identifying information.
Please answer the following questions and rate your answers from 1-5
1= very poor, 2= poor, 3=average, 4= good, 5= excellent
1. How would you rate the schedule and flow of the orientation week? 1 2 3 4 5
2. How efficient was the case management orientation process with your time? 1 2 3 4 5
3. How well did your case management orientation meet all of your expectations? 1 2 3 4 5
4. How would you rate your comfort level with and understanding of important policies and procedures that were reviewed?
1 2 3 4 5 5. How would you rate the computer training courses?
1 2 3 4 5
6. How would you rate your preparation and readiness to begin safely working on your unit? 1 2 3 4 5
7. How would you rate the amount of paperwork required of you during the case management orientation process?
1 2 3 4 5
8. Compared with other orientations you have experienced; how would you rate this case management orientation?
1 2 3 4 5
9. Overall how would you rate the case management orientation? 1 2 3 4 5
10. Overall how would you rate your unit orientation? 1 2 3 4 5
Please complete the following:
1. What scheduling changes can be made to improve the orientation week?
2. What else would have been beneficial to review with you during your case management orientation?
3. What specifically can be done to improve the case management orientation? 4. What specifically can be done to improve your unit orientation?
