Gardner-Webb University Digital Commons @ Gardner-Webb University Nursing Theses and Capstone Projects Hunt School of Nursing 2012 Assessing a Revised Case Management Orientation Program for Effectiveness Tammy S. Brown Gardner-Webb University Follow this and additional works at: http://digitalcommons.gardner-webb.edu/nursing_etd Part of the Nursing Commons Recommended Citation Brown, Tammy S., "Assessing a Revised Case Management Orientation Program for Effectiveness" (2012). Nursing Theses and Capstone Projects. Paper 105. This Thesis is brought to you for free and open access by the Hunt School of Nursing at Digital Commons @ Gardner-Webb University. It has been accepted for inclusion in Nursing Theses and Capstone Projects by an authorized administrator of Digital Commons @ Gardner-Webb University. For more information, please contact digitalcommons@gardner-webb.edu.
i 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 April 26, 2012 April 26, 2012
UMI Number: 1520137 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. UMI 1520137 Published by ProQuest LLC (2012). Copyright in the Dissertation held by the Author. Microform Edition ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106-1346
ii Assessing a Revised Case Management Orientation Program for Effectiveness Tammy S. Brown Gardner-Webb University
iii 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.
iv Table of Contents 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 Chapter V: Discussion... 28
v 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 Appendix C: Case Management Orientation Survey... 37
1 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.
2 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
3 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
4 (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
5 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
6 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
7 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
8 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 competencies during the six week orientation period at the researcher s facility.
9 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
10 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 semistructured 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
11 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.
12 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 (JulyDecember 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
13 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
14 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 discussion versus SML and time to complete both programs was equal (Carcich & Rafti,
15 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
16 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 & LeinoKilpi, 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
17 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-
18 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-forprofit 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
19 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
20 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 competencies during the six week orientation period at the researcher s facility.
21 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 posttestonly 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
22 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
23 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
24 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
25 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.
26 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 4.50 4.00 A v e r a g e 3.50 3.00 2.50 2.00 Average Before N=9 1.50 Average After N=6 1.00 0.50 0.00 1 2 3 4 5 6 7 8 9 10 Question Survey Instrument is a revised version of Lott s (2006) Nursing Orientation Survey used with permission.
27 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.