Queensland University of Technology
School of Nursing
Centre for Health Research
Effectiveness of a collaborative case management education program for Taiwanese public health nurses
Wen-I Liu RN, BN, MSN
Submitted for the award of Doctor of Philosophy
June 2007
I
KEYWORDS
Case management
Collaboration
Continuing professional education
Public health nurses
Case management knowledge
Case management skills
Case management practice
II
ABSTRACT
Taiwanese health authorities are increasingly applying case management as a
health care delivery strategy in the community. However, most Taiwanese public
health nurses (PHNs) do not receive case management education because there are
few education programs available. Several limitations in existing evaluative studies
of case management continuing education programs were identified. These
methodological weaknesses limit the conclusions that can be drawn about the
effectiveness of these education programs. Hence, the purpose of this study was to
develop, implement and evaluate a collaborative case management continuing
education program for Taiwanese PHNs.
The study was divided into three phases, with an expanded theoretical
framework used to guide the program development, implementation and evaluation.
Phase One conducted focus group discussions in order to assess the educational
needs of Taiwanese PHNs. Phase Two developed a collaborative education program
based on the findings of a literature review and the needs assessment. The initial
program was evaluated by an expert panel and pilot testing was undertaken. Phase
Three implemented and evaluated the program using an experimental research design
and mixed evaluation methods. Three outcome levels were assessed, namely reaction,
learning and performance by examining changes in PHNs’ case management
knowledge, skills and practice. The participants in the study were PHNs employed in
health centres in Taipei City. The program itself involved 16 hours of workshops
through four half-day sessions, conducted every two weeks during the participants’
work time and at their workplace.
III
Two types of data, focus group data and questionnaire data, were collected
during the course of the study. The focus groups were conducted before and after the
program delivery, for the needs assessment and program evaluation, using a subset of
the participants. The focus groups were moderated by the researcher, who used a
focus group discussion guide to collect data. The other data set was collected using
self-report questionnaires. The participants were randomly allocated into two groups
using cluster sampling, the experimental and comparison groups. Both groups were
given questionnaires before the education program commenced, and then again eight
weeks after the program was completed. For ethical considerations, PHNs in the
comparison group also received the same program after data collection.
The results revealed that the majority of participants were satisfied with the
program. The education intervention significantly improved PHNs’ case
management knowledge, performance skills confidence, preparedness for case
manager role activities, frequency of using case management skills, and frequency of
using these role activities. A number of changes in case management practice were
reported, in particular that the participants tended to follow the case management
process more often and focus more on the quality of case management. This study
was guided by an integrated theoretical framework, and used a clustered randomised
controlled design to assess the effectiveness of the program across multiple levels of
outcomes, hence addressing the design deficits identified in the prior evaluative
studies. This study therefore provides an important contribution to the fields of
nursing and case management by developing, implementing and evaluating a case
management education program. Additionally, the program itself offers an evidence-
based educational experience for PHNs and provides a new tool for nursing
education in the context of Taiwan.
IV
TABLE OF CONTENTS
KEY WORDS IABSTRACT IITABLE OF CONTENTS IVLIST OF TABLES VIIILIST OF FIGURES IXLIST OF APPENDICES XSTATEMENT OF ORIGINAL AUTHORSHIP XIACKNOWLEDGMENTS XIICHAPTER ONE INTRODUCTION 1 1.1 Study Background 2 1.2 The Purpose, Objectives, and Research Questions 7 1.2.1 Purpose and Objectives 7 1.2.2 Research Questions 8 1.2.3 Research Hypotheses 9 1.3 Significance of the Study 10 1.4 Definition of Terms 11 1.5 Structure of the Thesis 14CHAPTER TWO LITERATURE REVIEW OF CASE MANAGEMENT 16 2.1 Overview of Case Management Practice 16 2.1.1 Case Management: Definitions 16 2.1.2 Characteristics of Case Management 19 2.2 Types of Case Management Implementations 22 2.3 Requirements of Case Managers 26 2.3.1 Who is an Appropriate Case Manager? 26 2.3.2 Nurses and Case Management 28 2.3.3 Nurse Case Manager Roles 30 2.3.4 Preparing Nurses to be Case Managers 33 2.3.4.1 Knowledge Requisites for Case Management 35 2.3.4.2 Required Case Management Skills 37 2.3.4.3 Training for Case Manager Role Activities 39 2.4 The Development of Case Management in Taiwan 42 2.4.1 Hospital-based Case Management and Nurse Education 44 2.4.2 Long-term Care Case Management and Nurse Education 45 2.4.3 Community-based Case Management and Nurse Education 47 2.4.4 Differences between these Three Case Management Programs 49 2.5 Public Health Nurses’ Preparation for Case Management 49 2.5.1 Rationale for Preparing Public Health Nurses as Case Managers 50 2.5.2 Educational Needs for Public Health Nurses in Taiwan 51 2.5.3 Strategies to Prepare Public Health Nurses for Case Management 52 2.6 Summary 55CHAPTER THREE LITERATURE REVIEW ON CASE MANAGEMENT EDUCATION 57 3.1 Continuing Professional Education (CPE) 57
V
3.1.1 Evaluation of CPE 57 3.1.1.1 Level I: Reaction Evaluation 59 3.1.1.2 Level II: Learning Evaluation 60 3.1.1.3 Level III: Performance Evaluation 61 3.1.1.4 Level IV: Impact Evaluation 61 3.1.2 Effectiveness of CPE 63 3.1.2.1 Impact on Nurses’ Knowledge and Skills 64 3.1.2.2 Impact on Nursing Practice and Patient Care 65 3.1.3 Factors Influencing the Effectiveness of CPE 68 3.1.3.1 Individual Factors 69 3.1.3.2 Educational Factors 71 3.1.3.3 Organisational Factors 75 3.2 Case Management Continuing Professional Education 76 3.2.1 Award CM Educational Programs 77 3.2.2 Non-award CM Educational Programs 78 3.3 Review of CMCPE Programs 82 3.3.1 Program Design 83 3.3.2 Research Design for Evaluation 89 3.3.3 Outcome Measures 91 3.3.3.1 Knowledge 91 3.3.3.2 Skills 93 3.3.3.3 Practice 94 3.4 Limitations and Gaps in Existing Research 97 3.5 Summary 98CHAPTER FOUR THEORETICAL FRAMEWORK OF PROPOSED PROGRAM 104 4.1 Introduction 104 4.2 Overview of the CCMCPE Program Framework 104 4.3 Theoretical Basis of the Framework 107 4.4 Structure: Factors Influencing the Effectiveness of CCMCPE 109 4.4.1 Individual Factors of PHNs 110 4.4.2 Educational Factors 110 4.4.3 Organisational Factors 112 4.5 Process: Implementing the CCMCPE program 113 4.6 Outcomes: Levels of Evaluation 114 4.7 Limitations of this Research 116 4.8 Summary 117CHAPTER FIVE PHASE ONE: EDUCATIONAL NEEDS ASSESSMENT 119 5.1 Introduction 119 5.2 Research Design 119 5.3 Method 121 5.3.1 Sampling and Recruitment 122 5.3.2 Moderation of Focus Groups 124 5.3.3 Standardised Data Collection Procedures with Discussion Guide 125
VI
5.4 Data Analysis 128 5.4.1 Qualitative Data Analysis Method 128 5.4.2 Procedures of Qualitative Content Analysis 130 5.5 Results and Discussion of Focus Groups 134 5.5.1 Current Case Management Knowledge 135 5.5.2 Current Case Management Practice 137 5.5.3 Learning Needs 139 5.5.4 Preferred Learning Methods 140CHAPTER SIX PHASE TWO: PROGRAM DEVELOPMENT AND PILOTING 144 6.1 Initial Development of Intervention 144 6.1.1 Findings from the Literature Review 144 6.1.2 Results from the Needs Assessment 146 6.1.2.1 Assessing learners factors 147 6.1.2.2 Assessing Organisational Factors 148 6.1.2.3 Assessing Educational Factors 149 6.1.3 Initial Program Development 152 6.2 Expert Panel Review 159 6.3 The Instruments: Psychometric Data 163 6.3.1 Measures 164 6.3.1.1 Section One - Case Management Knowledge 164 6.3.1.2 Section Two - Case Management Skills 166 6.3.1.3 Section Three - Case Manager Role Activities 169 6.3.1.4 Section Four - Demographic Data and Evaluation Data 172 6.3.2 Tool Translation 172 6.3.3 Validity Examination of the Instruments 173 6.3.3.1 Content Validity 173 6.3.3.2 Face Validity 175 6.3.4 Reliability Tests of the Instruments 176 6.3.4.1 Internal Consistency 180 6.3.4.2 Test-retest Reliability 181 6.4 Pilot Testing the CCMCPE Program 186 6.5 Summary 190CHAPTER SEVEN PHASE THREE: EVALUATION STUDY 191 7.1 Research Design 191 7.2 Ethical Considerations 196 7.3 Research Method 198 7.3.1 Setting and Sampling 198 7.3.2 Measures 201 7.3.3 Procedures for Data Collection 207 7.3.3.1 Quantitative Data Collection 207 7.3.3.2 Qualitative Data Collection 210 7.3.4 Data Management and Analysis 211 7.3.5 Intervention 214
VII
7.4 Results of the Quantitative Data Analysis 218 7.4.1 Demographic Characteristics of Participants 219 7.4.2 Descriptions of Outcome Variables 220 7.4.2.1 Knowledge 222 7.4.2.2 Skill Confidence 223 7.4.2.3 Skill Frequency 223 7.4.2.4 Activity Preparedness 223 7.4.2.5 Activity Frequency 224 7.4.3 Evaluation of Educational Intervention 224 7.4.3.1 Question 1 (Level I) 225 7.4.3.2 Question 2.1 (Level II) 226 7.4.3.3 Question 2.2 227 7.4.3.4 Question 2.3 228 7.4.3.5 Question 3.1 (Level III) 230 7.4.3.6 Question 3.2 231 7.5 Summary of the Quantitative Results 232 7.6 Findings from the Qualitative Data 233 7.6.1 Current Case Management Knowledge 235 7.6.2 Current Case Management Practice Change 236 7.6.3 Factors Influencing Changes 238 7.6.4 Overall Program Feedback 239CHAPTER EIGHT DISCUSSION AND CONCLUSION 241 8.1 Level I: Reaction Evaluation 243 8.2 Level II: Learning Outcomes Evaluation 244 8.3 Level III: Performance Outcomes Evaluation 250 8.4 Strengths of the Study 254 8.5 Limitations of the Study 257 8.6 Implications 259 8.6.1 Implications for Education 259 8.6.2 Implications for Practice 262 8.6.3 Implications for Research 263 8.7 Recommendations for Further Work 265 8.8 Conclusion 266APPENDICES 268REFFERENCES 373
VIII
LIST OF TABLES
TABLE 2.1 Comparison of three key types of case management 23
TABLE 2.2 Essential knowledge areas identified for case management education 36
TABLE 2.3 Essential case management skills 39
TABLE 2.4 Selected case manager role activities 41
TABLE 3.1 Summary of selected case management continuing education studies 100
TABLE 5.1 Stages of qualitative data analysis 131
TABLE 5.2 Categories of the focus groups (needs assessment) 134
TABLE 6.1 Initial case management education program 154
TABLE 6.2 Initial course content framework of the CCMCPE program 155
TABLE 6.3 Learning strategies of the CCMCPE program 157
TABLE 6.4 Initial learning plans for the CCMCPE program over four sessions 160
TABLE 6.5 Variables and measures 164
TABLE 6.6 Summary of pilot test participants’ demographic data 179
TABLE 6.7 Pilot test: Descriptive data for the outcome variables 181
TABLE 6.8 Test of reliability 182
TABLE 7.1 Summary of instrument quality 208
TABLE 7.2 Characteristics of participants by group (age and nursing experience) 221
TABLE 7.3 Characteristics of participants by group (gender, education level and prior training) 221
TABLE 7.4 Descriptive statistics and pre-test differences on outcome variables 222
TABLE 7.5 Outcome variables scores of pre-test and post-test by two groups 225
TABLE 7.6 Categories of the focus group after the educational intervention 234
TABLE 8.1 The strategies used to enhance learning outcomes 248
IX
LIST OF FIGURES
FIGURE 4.1 Theoretical framework of the proposed program 105
FIGURE 6.1 Bland-Altman plot for knowledge scores 183
FIGURE 6.2 Bland-Altman plot for skill confidence 184
FIGURE 6.3 Bland-Altman plot for skill frequency 184
FIGURE 6.4 Bland-Altman plot for activity preparedness 185
FIGURE 6.5 Bland-Altman plot for activity frequency 186
FIGURE 7.1 Research Design for experimental evaluation study 193
FIGURE 7.2 Sampling strategies to determine the study sample in Taipei City, Taiwan 199
FIGURE 7.3 Bland-Altman plot for reproducibility of knowledge scores 204
FIGURE 7.4 Bland-Altman plot for reproducibility of skill confidence 205
FIGURE 7.5 Bland-Altman plot for reproducibility of skill frequency 205
FIGURE 7.6 Bland-Altman plot for reproducibility of activity preparedness 206
FIGURE 7.7 Bland-Altman plot for reproducibility of activity frequency 207
FIGURE 7.8 Graph of time × group interaction on knowledge 227
FIGURE 7.9 Graph of time × group interaction on skill confidence 228
FIGURE 7.10 Graph of time × group interaction on activity preparedness 229
FIGURE 7.11 Graph of time × group interaction on skill frequency 231
FIGURE 7.12 Graph of time × group interaction on activity frequency 232
X
LIST OF APPENDICES
Appendix 1.1 Information sheet 269
Appendix 1.2 Consent form 271
Appendix 1.3 Invitation letter to public health nurses 272
Appendix 1.4 Directions for completing the questionnaire 273
Appendix 2.1 Focus Group Discussion Guild (before pre-tests) 274
Appendix 2.2 Focus Group Discussion Guild (after post-tests) 275
Appendix 2.3 Transcript of focus group discussions (before intervention) 276
Appendix 2.4 Transcript of focus group discussions (after intervention) 286
Appendix 3 Learning manual of the educational program 295
Appendix 4.1 Expert panel evaluation sheet 317
Appendix 4.2 Expert panel covering letter with instructions 318
Appendix 4.3 Expert panel Content Validity Inventory 319
Appendix 5.1 Permissions agreement from Jones and Bartlett Publishers 325
Appendix 5.2 Instrument approval of the Practice Skills Inventory-Case Management Skills 326
Appendix 5.3 Instrument approval of the Case Management Activity Scale 327
Appendix 6.1 Section One: A comparison between two versions of Knowledge Index 328
Appendix 6.2 Section Two: Adopted and developed items of Case Management Skills 331
Appendix 6.3 Section Three: Comparison between two versions of Case Management Activity 332
Appendix 6.4 Section Four: Demographic Data and Evaluation Data 334
Appendix 7.1 Ethical approval from Queensland University of Technology 335
Appendix 7.2 Ethical approval from National Taipei College of Nursing 336
Appendix 8 Approval of the twelve health centres in Taipei City (Appendix 8.1 - 8.12) 337
Appendix 9.1 Questionnaire in English 350
Appendix 9.2 Questionnaire in Chinese 362
XI
STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
Signature: Wen-I Liu
Date: 12 June 2007
XII
ACKNOWLEDGMENTS
Firstly, I would like to thank my principal supervisor, Professor Helen
Edwards, who critically guided my logical thinking and provided constructive
criticism for my thesis writing. I would also like to extend my thanks to my associate
supervisor, Professor Mary Courtney, for her encouragement, as this support has
made it possible for me to extend myself to achieve my goals. Thank you also to the
Queensland University of Technology for offering me an International Doctoral
Scholarship to complete the PhD program. My gratitude also to my school, the
National Taipei College of Nursing, for supporting my PhD study overseas and
ensuring my teaching job remained available for me.
I also appreciate the involvement of all of these individuals and organisations.
In addition, I was extremely lucky to have the support of a grant from the National
Science Council, in Taiwan. As an international student, I would also like to thank
Martin and Janie, both of whom assisted me helped me in the writing of this thesis.
Thanks also go to my friends and colleagues for supporting me throughout.
In terms of personal thanks, I need to extend my gratitude to my little son,
who is the same age as my PhD journey. His mom brought him overseas and then
had to leave him in Taiwan when he was only one month old. Finally, thanks to my
wonderful husband for covering my responsibilities by taking care of our three
beautiful children, and to my mother-in-law for helping me take care of my husband
and make sure I had a home to return to. The four years of my PhD journey have
been exceptional. My continual belief in myself and my confidence that I could
complete the PhD helped keep me motivated, and will allow me to assist others
contemplating the same journey.
1
CHAPTER ONE
INTRODUCTION
This thesis describes the development and evaluation of a collaborative case
management continuing professional education (CCMCPE) program for public
health nurses (PHNs) in Taiwan. Case management (CM) is increasingly being
adopted as a care delivery model around the world, in the light of evidence that it is
associated with a range of positive outcomes (Barton, Clark, & Baramee, 2004;
Schein, Gagnon, Chan, Morin, & Grondines, 2005; Schulte, Musolf, Meurer, Cohn,
& Kelly, 2004; Schumacher, 2003). In Taiwan, one field in which case management
has been applied is in the community, and thus Taiwanese PHNs employed in
community health centres are often required to act as case managers. In order to
achieve effective case management outcomes, such PHNs need to acquire new
knowledge and skills relating to case management. However, until the current study
most Taiwanese PHNs had not received case management education or training
because there are no formal academic education programs established in this field,
and few continuing education programs available.
One means of designing and implementing case management education is
through collaboration between academia and public health nursing practice using
multiple learning strategies (Morrison, Stone, & Wilson, 2005; Robertson, Umble, &
Cervero, 2003). However, a review of the relevant literature revealed that existing
case management education programs often lack a theoretical basis, and existing
evaluation studies of such programs tend to contain methodological weaknesses. No
studies exist examining the effectiveness of a collaborative educational intervention
for public health nurses. To address these issues, a collaborative case management
2
education program was developed, guided by an integrated framework, and then
delivered to a sample of Taiwanese PHNs. The effectiveness of the program was
assessed using mixed evaluation methods.
1.1 STUDY BACKGROUND
Case management is “a collaborative process that assesses, plans, implements,
coordinates, monitors and evaluates the options and services required to meet an
individual’s health needs, using communication and available resources to promote
quality, cost-effective outcomes” (Case Management Society of America, 2005, p. 8).
During case management individual members of the community are assisted by
knowledgeable and skilled healthcare professionals called case managers whose role
is to manage and coordinate services to meet patient needs. The high cost of health
care and the current focus on client-centred care requires health care systems to
balance quality care improvements with cost control. CM is one means of meeting
the demand for health care systems to achieve better health care quality while also
saving costs, and has been widely used in many countries (Dickerson & Mansfield,
2003).
Based on evidence of its effectiveness, case management strategies are
currently being implemented in a variety of settings with different populations under
a range of conditions. Several studies have demonstrated the effectiveness of case
management programs both in terms of health-related outcomes for clients and cost-
effectiveness (Barton et al., 2004; Schein et al., 2005; Schulte et al., 2004;
Schumacher, 2003). These outcomes include better quality of life, higher client
satisfaction, better functional status and health status, fewer symptoms, fewer days
spent in hospital, and lower health care costs. Hence, CM has been applied in
3
hospitals, community and long-term care, and is visible in almost every area of
health care (Cohen & DeBack, 1999; Lamb, Donaldson, & Kellogg, 1998; Mullahy,
1995).
In response to this global trend of applying case management in health care
systems, health care professions – including nursing, social work, psychology and
other disciplines – have prepared professionals for new roles as case managers
(Kulbok & Utz, 1999). In the nursing profession, essential training and education has
become available to help nurses assume their case manager roles, in turn meeting the
demands of the job marketplace. In the USA, many academic case management
education programs, and continuing professional education programs such as
orientation, online training or collaborative professional education have been
established to meet the marketplace drivers (Cesta & Tahan, 2003).
There is clear evidence that training and education in case management is
associated with better care outcomes and reduced costs (Barney, Rosenthal, & Speier,
2004; Lancashire, Haddock, Tarrier, & Baguley, 1997; Stanard, 1999). Nurses acting
as case managers need knowledge and skills to allow them to successfully undertake
effective and comprehensive case management practice. A case manager’s
educational preparation is the key to successful case management (Cohen & Cesta,
2005a; Stanard, 1999). According to Donabedian’s (2003) model, the training of
professionals (known as structure factors in this model) influences the process of
case management and subsequently affects client outcomes. Hence, nurses’
knowledge, skills and practice influences the quality of the case management service
delivery and hence influences client outcomes.
The Taiwanese health care system has, as many other countries have around
the world, adopted case management as a care delivery method. Community case
4
management in particular has been applied in Taiwan and public health nurses are
generally required to act as case mangers. In order to care for community-based
vulnerable populations, the Taipei City government applied case management as a
health service method to ensure these populations obtained needed services. In this
system PHNs act as case managers by providing links to needed services for people
with mental illness and older adults living alone in the community (Taipei City
Government, 2003). The role fulfilled by Taiwanese public health nurses has
therefore changed, as they are now required to be case managers, with a focus on
communication, coordination and cooperation with other professionals (Tai, 2004).
However, Taiwanese public health nurses are in a particularly vulnerable situation.
They have not been prepared for their community-based case management practice
through education or training, but are nevertheless required to perform a range of
case management activities as part of their essential daily work.
In light of the current system, Taiwanese public health nurses need to be
prepared both in terms of theory and practice with regard to case management. This
is reinforced by nursing faculty and nurse case managers, who believe strongly that
case management content should be included in nursing education programs (Kuric
& White, 2005). The educational needs regarding case management for PHNs in
Taiwan have previously been identified by an expert panel (Lee, 2000), and many
researchers have called for the development of systematic case management
education programs for PHNs and case managers in Taiwan (Lee, 1999; 2000; Yang,
2003). However, to date there are few educational programs providing PHNs with
the essential knowledge and skills to prepare them for case management practice,
despite the fact that the job market demands that they have these competencies.
There is thus no doubt that PHNs need to be educated and prepared for case
5
management practice to assume successful case management work and to contribute
to positive client outcomes.
Collaboration between nursing academia and clinical nurses is the current
trend in continuing education (Cervero, 2000; Knox, 2000). Evidence suggests that
such collaboration greatly enhances positive educational outcomes (Morrison et al.,
2005). Collaborative education programs offer a unique opportunity for clinical
nurses to gain on-site practice and for academics and clinical nurses to build
partnerships and work together. Collaborative programs also emphasise collaborative
learning which uses structured small-group activities to promote learning (Fink,
Michaelsen, & Knight, 2002). Collaboration between nursing academia and clinical
nurses may also provide a means of overcoming one of the existing limitations in this
field, namely the lack of experienced case managers to teach case management (Haw,
1996). Most case managers’ abilities and confidence have emerged from continuing
education programs, rather than prior educational preparation or training (Marzke,
1995). Evidence has shown that case management continuing professional education
programs are successful in producing beneficial changes in knowledge, skills and
nursing performance (Connors, 1992; Dickerson & Mansfield, 2003; Matrone, 1990).
Hence, collaborative continuing professional education can be considered an
effective strategy to meet Taiwanese public health nurses’ emergent case
management education needs.
Learning strategies based on transformative theory should be considered in
the current project, as a means of linking the concepts learned in the classroom to
real-life practice (Melnyk, Fineout-Overholt, & Feinstein, 2004). Educational theory
explains the role of learning in professional practice and the process by which
learning and change occur (Mann, 2004). Hence, a learning theory and a series of
6
learning strategies guided the program’s design and focused on linking case
management theory to the PHNs’ case management practice. Transformative
learning allows CPE providers to integrate learning and context within educational
activities. It regards learning as a critically reflective process wherein learners
ultimately assess their previous understanding to determine whether those
assumptions still hold in the learner’s present situation (Mezirow, 2000). Hence the
program incorporated effective strategies drawn from transformative learning and
identified from literature, as well as a needs assessment to foster positive outcomes.
Thus, this program adapted to PHNs’ preferred learning methods and aimed to
achieve multiple educational outcomes—including knowledge, skills and practice—
to enhance changes in case management and to help the PHNs undergo role
transformation.
A review of the relevant literature reveals gaps in previous research with
regard to available case management education programs, and effective evaluation
research into these programs, for nurses or case managers. First, there is no
documented information concerning Taiwanese public health nurses’ knowledge of
case management and their case management practice. Thus a needs assessment is
necessary to confirm their knowledge and practice gaps to confirm their case
management educational needs. Second, although many case management education
programs have been developed in other countries to prepare nurses as case managers,
few such case management education programs are offered to PHNs and no
evaluation study has been conducted in this field in Taiwan. Third, existing case
management education programs often lack a theoretical basis to guide the
educational program development, delivery and evaluation. Fourth, no collaborative
program has been comprehensively evaluated using multiple level evaluations
7
(including reaction, learning outcomes and performance changes). Finally, existing
evaluation studies have contained methodological weaknesses and have failed to
offer strong, reliable evidence for the effectiveness of specific education programs in
the case management field. It is clear that further research is needed to address these
issues.
Given the state of case management education programs, this study aimed to
design, deliver and evaluate a collaborative case management professional education
(CCMCPE) program for public health nurses in Taiwan. An integrated framework
was used to guide the development, delivery and evaluation of the CCMCPE
program. This research identified PHNs’ case management educational needs to
ascertain required course content in the nursing education program. The study
explored PHNs’ current knowledge of case management, current case management
practice and preferred learning methods. A CCMCPE program was developed on the
basis of the literature review and the needs assessment and evaluated by an expert
panel review and pilot test. This research also sought to identify whether there was
an improvement in reaction, learning and performance outcomes associated with
completion of the CCMCPE.
1.2 THE PURPOSE, OBJECTIVES, AND RESEARCH
QUESTIONS
1.2.1 Purpose and Objectives
The purpose of the study was to develop, implement and examine the effects
of the CCMCPE program in terms of changing Taiwanese public health nurses’
knowledge, skills and practice in case management. The objectives of the research
project were threefold. The first objective, addressed in Phase One, was to conduct
8
focus groups to identify the PHNs’ educational needs in relation to case management.
The second objective, addressed in Phase Two was to develop and pilot a CCMCPE
program for public health nurses in Taiwan. The third objective, addressed in the last
phase was to implement and evaluate the CCMCPE program for public health nurses
in Taiwan. In order to achieve the purpose and objectives, the following research
questions, developed from the literature, were examined for public health nurses who
were employed in the community health centres of Taipei City.
1.2.2 Research Questions
The main research question in Phase One was: What are PHNs’ educational
needs in relation to case management? Sub-questions addressed within this phase
were:
1. What is public health nurses’ current knowledge of case management (CM)?
2. How do public health nurses practice CM?
3. What are public health nurses’ CM learning needs?
4. What are public health nurses’ preferred learning methods?
The four research questions and sub-questions addressed within Phase Three
(experimental evaluation study) were:
• Question 1: Are the PHNs satisfied with the CCMCPE program? (Level I)
• Question 2: Is the CCMCPE program effective in improving PHNs’ learning
outcomes? (Level II)
2.1 Is there a difference in self-reported knowledge about case management
between public health nurses who received the case management continuing
professional education program and those who did not?
9
2.2 Is there a difference in self-reported performance confidence in case
management skills between public health nurses who received the case
management continuing professional education program and those who did not?
2.3 Is there a difference in level of self-reported preparedness for case manager
role activities between public health nurses who received the case management
continuing professional education program and those who did not?
• Question 3: Is the CCMCPE program effective in improving PHNs’ performance
outcomes? (Level III)
3.1 Is there a difference in self-reported frequency of using case management
skills between public health nurses who received the case management
continuing professional education program and those who did not?
3.2 Is there a difference in level of self-reported frequency of using case manager
role activities between public health nurses who received the case management
continuing professional education program and those who did not?
• Question 4: Are there changes in case management practice for those who
attended the collaborative case management continuing professional education
program? If yes, how has practice changed? If not, what factors hinder changes?
A mixed evaluation method was used to assess the effectiveness of the
program. The technique included both a quantitative approach, using an experimental
evaluation study with pre- and post- testing of experimental and comparison groups,
and a qualitative approach through focus groups with a subset of participants.
1.2.3 Research Hypotheses
In order to answer the research questions, the study established and examined
the following hypotheses.
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1. Public health nurses who receive the CCMCPE program will be satisfied with
the CCMCPE (Research Question 1).
2. Public health nurses who receive the CCMCPE program will report higher
levels of knowledge about case management compared to those who do not
receive the program (Research Question 2.1).
3. Public health nurses who receive the CCMCPE program will report higher
performance confidence in case management skills compared to those who do
not receive the program (Research Question 2.2).
4. Public health nurses who receive the CCMCPE program will report a higher
level of preparedness for case manager role activities compared to those who do
not receive the program (Research Question 2.3).
5. Public health nurses who receive the CCMCPE program will report greater use
of case management skills compared to those who do not receive the program
(Research Question 3.1).
6. Public health nurses who receive the CCMCPE program will report greater use
of case manager role activities compared to those who do not receive the
program (Research Question 3.2).
7. Public health nurses who receive the CCMCPE program will report changes in
their case management practice (Research Question 4).
1.3 SIGNIFICANCE OF THE STUDY
This study sought to contribute to the development and evaluation of a
collaborative case management education program in the following ways.
1. The study will identify the case management educational needs of Taiwanese
public health nurses through focus groups.
11
2. The tools used to examine nurses’ case management knowledge, case
management skills, and case manager role activities will be translated and
tested for use with this particular Taiwanese nursing population.
3. The study will provide an understanding of Taiwanese public health nurses’
current knowledge, skills and practice in case management.
4. The CCMCPE program will be developed based on an integrated theoretical
framework for public health nurses, thus addressing the deficit of existing case
management continuing education programs.
5. The collaborative education program itself will provide an addition to the
evidence-based educational resources for public health nurses.
6. The education intervention will address the gap between case management
education and practice in Taiwan
7. The findings of this study will address the gaps in the literature related to
evaluation of the effectiveness of CCMCPE programs for public health nurses.
8. The development, implementation and evaluation of a CCMCPE program will
contribute to the current knowledge about the effectiveness of collaborative
education interventions in improving public health nurses’ knowledge, skills
and practice in case management.
1.4 DEFINITION OF TERMS
The focus of this study is the assessment of the effectiveness of a
collaborative case management education program for Taiwanese public health
nurses, and thus several key terms need to be defined, both conceptually and
operationally. These terms are case management, collaborative case management
12
continuing professional education program, public health nurses, case management
knowledge, case management skills, and case management practice.
Case management
Conceptual definition: A collaborative process that assesses, plans,
implements, coordinates, monitors and evaluates the options and services required to
meet an individual’s health needs, using communication and available resources to
promote quality, cost-effective outcomes (Case Management Society of America,
2005).
Operational definition: A systematic method for health care delivery offered
by Taiwanese public health nurses, including a set of service activities such as case
identification, assessment, planning, coordination, monitoring and evaluation
activities.
Collaborative case management continuing professional education program
Conceptual definition: Clinical nurses and academics establish a collaborative
relationship and work together with a set of planned learning activities intended to
enhance nurses’ case management practice (American Nurses Association, 2000;
Papenhausen et al., 1999).
Operational definition: A program comprised of a series of structured
workshops that incorporate multiple learning strategies, and are intended to enhance
public health nurses’ knowledge, skills, and practice activities of case management.
There are two different dimensions of collaboration in this program; collaboration
between nursing academia and public health nurses; and collaborative learning by
participants. The program was facilitated by a nursing academic working with public
health nurses to learn case management practice. The second dimension involved
13
collaborative learning among the public health nurses through the use of small
groups with a set of structured learning activities.
Public health nurses
Conceptual definition: Registered nurses who provide care to individual
patients or groups in community settings (Stedman, 2005).
Operational definition: In this study a public health nurse is defined as a staff
member responsible for all citizens living in the community and who has worked in a
health service centre for at least six months in Taipei City, Taiwan and is not
receiving any other training about case management at the time of recruitment.
Case management knowledge
Conceptual definition: Knowledge refers to what one knows, as through
study or experience (Walter, 2005). Case management knowledge means what one
knows and understands about case management related concepts and components.
Operational definition: Case management knowledge refers to what an
individual knows about case management related concepts and process, as measured
by the Case Management Knowledge Index.
Case management skills
Conceptual definition: Skills refers to techniques or abilities which are
developed or acquired through training or experience (Walter, 2005). Case
management skills are those abilities or techniques related to case management
practice.
Operational definition: Case management skills refer to essential techniques
or abilities related to the case management process, communication and leadership
14
which are needed in case management practice as measured by the Case
Management Skill Scale (O’Hare, Collins & Walsh, 1998).
Case management practice
Conceptual definition: Case management practice refers to a set of activities
that case managers undertake in the case management process (Cohen & Cesta,
2005b).
Operational definition: Case management practice refers to those activities
that nurses case managers conduct in their daily case management work as measured
by Anderson-Loftin’s (Anderson-Loftin & Stiles, 1999) Case Management Activity
Scale.
1.5 STRUCTURE OF THE THESIS
The thesis is presented in eight chapters. Chapter One has briefly presented
the background of the research project. The purpose, objectives, research questions,
and research hypotheses were specified. The significance of the study was presented,
and a definition of essential terms and the structure of the thesis outlined.
Chapter Two overviews the characteristics of case management and discusses
a range of practice issues related to case management. This chapter also examines the
role requirements of case managers and the case for continuing professional
education in case management for Taiwanese public health nurses.
Chapter Three describes existing case management education programs and
related concepts in continuing professional education, including factors influencing
the effectiveness of such programs. Recent evaluations of case management
continuing professional education programs are also reviewed.
15
Chapter Four provides the theoretical basis that guides the development,
implementation and evaluation of the program. An overview of the CCMCPE
program framework is presented. The research project integrates factors identified in
the literature as influencing effectiveness and uses three levels of outcome evaluation.
Chapters Five, Six and Seven provide the detailed methods and results of the
three phases of the study. Chapter Five describes the implementation of a needs
assessment through focus group discussions in order to explore public health nurses’
case management education needs. This chapter presents the research design,
research questions, details of the focus group method, qualitative data analysis, and
the results and a discussion of the findings. Chapter Six describes the development
and piloting of the collaborative case management continuing professional education
program and the study instruments. Chapter Seven describes the evaluation process,
including the experimental design of the study and a focus group to examine the
effect of the educational intervention on public health nurses’ knowledge, skills and
practice related to case management. The research design, research methods,
educational intervention, and the results of quantitative and qualitative data are
outlined.
Chapter Eight discusses the three levels of evaluation used here, in the
context of existing literature. This chapter also describes the strengths and limitations
of the study and implications for education, practice and research.
16
CHAPTER TWO
LITERATURE REVIEW OF CASE MANAGEMENT
In order to address the purposes of the current study, this chapter discusses
case management and related issues. It is divided into three main parts. The first part
describes the characteristics of case management and raises a range of practice issues.
The second discusses role requirements for nurse case managers. The final part
focuses on the subject population of the study by describing the evolution of case
management in Taiwan, and presenting the case for continuing professional
education for Taiwanese public health nurses in case management.
2.1 OVERVIEW OF CASE MANAGEMENT PRACTICE
In order to clarify the concept of case management, this section describes the
specific characteristics of case management and issues in case management practice.
2.1.1 Case Management: Definitions
There are a variety of definitions of case management provided by different
associations, organisations and experts (American Nurses Association, 1988; Cohen
& Cesta, 2005b; Commission for Case Manager Certification, 2005; Frink &
Strassner, 1996; Hyduk, 2002; Lee, Mackenzie, Dudley-Brown, & Chin, 1998) but to
date there is no clear agreement about the definition of case management in the
literature. Case management (known as CM) can be variously conceptualised as a
health care delivery system, a service delivery process, a method of managing the
provision of health care, a coordination of a specific group of services, or a
multidisciplinary clinical system. The use of various models, settings and types of
17
professionals has resulted in the generation of the different definitions seen in the
literature today (Lee et al., 1998). In order to clarify the concept of case management
for this study, there is a need to provide a specific definition.
Perhaps the most commonly cited definition of case management is from the
Case Management Society of America, who stated that, “case management is a
collaborative process which assesses, plans, implements, coordinates, monitors and
evaluates options and services required to meet an individual’s health needs through
communications and available resources to promote quality, cost-effective
outcomes” (Case Management Society of America, 2005, P. 8). This definition
focuses on case management as a process, incorporating main practical activities that
case managers undertake. This is the definition adopted in the current study, not only
because it is so widely used, but also because it is practice oriented, important for the
focus of the current project.
Before exploring the characteristics of CM, however, it is necessary to clarify
the difference between case management and ‘managed care’. These labels are often
used interchangeably in the professional literature even though they are not
synonymous (Cohen & Cesta, 2005b; Powell, 2000). Managed care is a healthcare
delivery system aimed at managing the cost and quality of access to health care
(Cohen & Cesta, 2005a; Powell & Ignatavicius, 2001). In contrast, case management
is only one health care delivery method (amongst many) for integrating and offering
needed services for clients in a range of healthcare systems to achieve quality and
cost-effective outcomes. Hence, managed care is systems-oriented but case
management is people-oriented (Powell, 2000). Both managed care and case
management are used in Taiwan.
18
Recently, especially in the United Kingdom, the term case management has
been replaced with ‘care management’ because the latter focuses more on
comprehensive activities and care coordination (Jacobs, Hughes, Challis, Stewart, &
Weiner, 2006). In Taiwan, care management and care managers have been used
within the long-term care system (Dai, Chang, Lu, & Wu, 2004) because long-term
care management focuses on establishing a system of care for a particular group,
across the continuum of care to ensure seamless transition to the right services
provided at the right time, for example to frail elderly people (Dai et al., 2004).
However, this study focuses on case management rather than care management,
because it is examining a systematic health service delivery method for professionals,
and does not address the specific models or healthcare systems to deliver services for
individuals. Further endorsing the use of case management (rather than another term)
is the fact that it is commonly used in the nursing education curricula of universities
and colleges (Fletcher & Coffman, 1999; Howell, Prestwich, Laughlin, & Giga, 2004;
Lehna & Tholcken, 2001; Tholcken, Clark, & Tschirch, 2004) as they tend to treat
case management as a strategic care delivery method.
Case management is thus used in the present research (in accordance with the
definition of the Case Management Society of America, 2005) to describe the
coordination of health needs for cases or clients, and which often requires a one-to-
one interactive relationship for people in high-risk situations. The characteristics of
the CM process will be introduced in the following section, and the development of
CM in Taiwan will also be discussed.
19
2.1.2 Characteristics of Case Management
Most authors agree that the contemporary applications of CM were well
established in the USA by the 1970s, and had been adopted internationally by the
1980s (Bailey, 1989; Cohen & Cesta, 2005a; Reimanis, Cohen, & Redman, 2001). In
the 1990s various changes in health care, including increasing costs and the
introduction of client-centred care, promoted the increasing use of case management,
and this spread throughout health care and other social services. The case
management approach has been used as an alternative strategy for integrating,
coordinating, and advocating for individuals and groups requiring extensive health
care services in many countries (Huber, 2000).
The use of case management as a health care delivery model has steadily
increased in popularity all over the world, and has been successfully applied in many
countries such as the USA, Canada, the United Kingdom and Australia (Cooper &
Roberts, 2006; Forchuk, Ouwerkerk, Yamashita, & Martin, 2002; Jacobs et al., 2006;
Metcalfe et al., 2005; Tahan, 2005). CM strategies are used in a variety of settings
with different populations under a range of conditions (Case Management Society of
America, 2005). Several studies have demonstrated the effectiveness of case
management programs in terms of both health-related outcomes for clients and cost-
effectiveness. These outcomes include better quality of life, higher levels of client
satisfaction, better functional status and health status, reporting of fewer symptoms,
shorter hospital days, and lower costs. Hence CM can be seen in almost every area of
health care, including in hospitals, community settings, long-term care and palliative
care (Gensichen et al., 2006; Krein, Klamerus, Vijan, Lee, et al., 2004; Mitchell et al.,
2005; Vourlekis, Ell, & Padgett, 2005).
20
The adaptability of the CM approach is also evident in its widespread use in
the community, across fields such as aged care, mental health, disability, child
welfare and school-based programs. CM has been applied to provide services for a
variety of populations, including those with chronic illnesses, mental impairments,
physical impairments, sensory impairments and developmental disability, as well as
older people and medically frail persons (Bellack, Bennett, Gearon, Brown, & Yang,
2006; Goodwin, Satish, Anderson, Nattinger, & Freeman, 2003; Gursansky, Harvey,
& Kennedy, 2003; Howgego Yellowlees, Owen, Meldrum, & Dark, 2003; Smith &
Prelock, 2002).
The goals of CM programs can be generally divided into client-oriented and
organisational goals. Client-oriented goals focus on quality of life, health status,
functional status or symptom relief. Organisational goals are assessed through length
of stay in hospital, returns to hospital, client satisfaction and cost-effectiveness
(Powell, 2000; Powell & Ignatavicius, 2001; Scharlach, Giunta, & Mills-Dick, 2001).
Several studies have demonstrated the effectiveness of case management programs in
terms of both health-related outcomes for clients and cost-effectiveness (Barton,
Clark, & Baramee, 2004; Schein, Gagnon, Chan, Morin, & Grondines, 2005; Schulte,
Musolf, Meurer, Cohn, & Kelly, 2004; Schumacher, 2003).
Cost containment and concerns about quality of care are leading health care
institutions to consider case management as a way to improve patient care and
control costs. Using case managers to oversee the provision of patients’ care is an
increasingly used and recognised strategy to help ensure that patients receive needed
care and services and that those services are delivered in an efficient, quality, cost-
effective manner (Cohen & Cesta, 2005b).
21
Despite the positive outcomes associated with the use of case management in
health care, issues related to case management need to be continually addressed and
challenged within health care systems. For example, health care systems need to
establish a range of community resources that they can access for different
populations, encourage collaboration among different disciplines, and ensure
communication among service providers. Other case management issues that need
constant attention within health care systems include the division of labour between
professional and non-professional staff, education and training for case managers,
and quality assurance by demonstrating benefits in terms of patient outcomes and
economic savings. All such issues provide challenges to real-world case management
practice (HMO Workgroup on Care Management, 1999; National Chronic Care
Consortium, 2000).
The adoption of case management as a care delivery method is likely to be
associated with a shift in the associated context, specifically the emergence of a
supportive work environment and associated policies. There are a variety of
challenges related to this shift that require attention by any organisation seeking to
create or refine case management practice (National Chronic Care Consortium, 2000).
Such challenges include the ability to: consistently provide services in a complex
delivery system; link to community-based services effectively; evaluate outcome
effectiveness and data reporting processes; and address the educational needs and
skill sets of case managers (Cohen & Cesta, 2005b; National Chronic Care
Consortium, 2000). Some of these issues and challenges were addressed in this
literature review, in particular, factors related to case management practice and the
educational requirements of nurse case managers.
22
In case management practice, the case management process can be seen as
the core activities and responsibilities of case managers. The case management
process includes case identification, assessment, planning, coordination, monitoring,
and reassessment (Pecqueux, 2001). The case management process can be applied in
different ways or through different models. Different styles and settings of case
management lend themselves to different components and foci. However, the case
management process has many universal principles that may apply to all models of
case management. These models, which describe different types of implementing the
case management process, will be discussed in the next section.
2.2 TYPES OF CASE MANAGEMENT IMPLEMENTATIONS
A plethora of case management models are described in the social services,
health care, and nursing literatures—including nursing case management, social case
management, and long-term care case management (Conti, 1999; Dixon & Cash-
Howard, 2003; Huber, 2000; Hyduk, 2002; Scharlach et al., 2001; Simpson et al.,
2003). The categories of case management models described in the literature can be
differentiated broadly by setting, patient diagnosis or disease type, disciplines or
providers. Providers include hospitals, sub-acute and rehabilitation facilities,
physician’s offices, home care agencies, hospices, or mental health settings (Huber,
2000; Powell, 2000). These descriptions, however, cannot differentiate the
operational aspects of case management. In the literature, individual case
management models tend to be grouped into three generalised types according to
their features, activities and responsibilities of case managers, even though different
terms are used. These general groupings are the brokerage CM, clinical CM and
intensive CM (Huber, 2000; Scharlach et al., 2001; Simpson et al., 2003). Each
23
model has particular strengths and weaknesses and has produced many case
management programs. An overview of these three types of model is presented in
Table 2.1.
Table 2.1
Comparison of three key types of case management
(adapted from Huber, 2000; Scharlach et al., 2001; Simpson, Miller & Bowers, 2003)
Items Brokerage CM Clinical CM Intensive CM
Purposes/Goals Linking clients with needed services
Promoting access for ongoing and changing needs
Ongoing prevention of the progression of disability using an interdisciplinary approach
Setting/System Community-based setting USA health and social care systems
Managed care organisation Hospitals or community
A network of teams working within a community setting or a hospital
Populations Broadly defined Functional impairment
Functional impairment as well as medical needs with risk of needing costly services
Disability and those at high risk for institutionalisation or other high cost care
Activities Assessment Care plan Some brokering of services
Assessment Care plan development Implementation of some interventions
Assessment Care plan development Implementation Monitoring Evaluation
Case manager Professionals or non-professionals with advocates or administrative function
Qualified nurses or social workers requiring specific training and skills
Qualified nurses or social workers requiring specific training and skills
Strengths Low financial risk Fewer case managers needed Short-term service Requires less time
Some financial risk Short-term services Case managers with higher authority
Full services Intensive services Multidisciplinary Case managers with the highest authority
Weaknesses Case managers with less authority
Services may be intense More case managers needed
Case managers with limited authority High financial risk Long-term services Requires largest amount of staff time More case managers needed
24
So which type is more effective? Simpson and colleagues (2003) in two
systematic review articles concluded that although all CM models increased the
number of clients remaining in contact with services, there was insufficient evidence
to determine differences in effectiveness between the models. Havassy, Shopshire
and Quigley (2000) also compared the effect of two types of case management
models, the brokerage CM and the intensive CM, in terms of outcomes for substance
dependent patients. Yet again, the results did not suggest any different effectiveness
between the two CM types (Havassy, Shopshire, & Quigley, 2000).
Ziguras and Stuart’s (2000) meta-analysis examined 44 studies which
compared the effectiveness of the intensive case management model and the clinical
case management model in mental health case management. Thirty-five studies
compared intensive case management or clinical case management with usual care.
They concluded that both types of case management led to small to moderate
improvements in the effectiveness of mental health services, and that both case
management models were more effective than standard community services in terms
of reducing family burden, increasing family satisfaction with services, and lowering
cost of care. Nine of the studies directly compared intensive case management and
clinical case management. They concluded that intensive case management had some
demonstrable advantages over clinical case management in reducing hospitalisation.
However, the two types of case management were equally effective in reducing
symptoms, increasing clients’ contact with services, reducing dropout rates,
improving social functioning, and increasing client satisfaction.
Thus to date there is no clear evidence for the effectiveness of one CM model
over another in terms of across-the-board improvements in patient outcomes.
However, all case management models have been shown to be more effective than
25
traditional care, and are associated with an increased number of clients remaining in
contact with those services. This thesis must now focus on the selection of a suitable
case management model for implementation in a health care organisation.
There are multiple considerations when selecting and adapting a case
management model for a particular context. Selection of an appropriate model
depends on the needs of the organisation, the available resources and the expected
goals and outcomes (Cesta & Tahan, 2003). These include the elements of the patient
population to be served, in terms of age, educational level, financial resources, and
most frequent diagnoses (Powell, 2000). Organisational issues, including the
underlying mission, vision, long-term or short-term goals, organisational structure,
strengths and weaknesses, and human resources can also play an important role in
the selection of a CM model. The type of organisation providing the case
management program can also vary. It could be an independent case management
agency, or it may exist within a larger structure such as a day health setting, a home-
health setting, a hospital, or community-based centres. The type and source of
funding, as well as the key activities in which clients and case managers participate
are additional factors that need to be addressed when selecting a case management
model (Hall, Carswell, Walsh, Huber, & Jampoler, 2002; Powell, 2000; Severson,
2001). Matching a case management model with the needs of a particular population
is a crucial component in any successful case management program (Baugh &
Freeman, 2003). However, although organisational settings influence the way in
which case management is performed, as well as the roles of the case managers,
there is no evidence to suggest that one organisational setting for case management is
inherently better than another (Scharlach et al., 2001).
26
Note that regardless of the type of model chosen for implementation of case
management, the case management process discussed earlier can be used as a general
guideline. That is, although the goals of individual case management models may
differ (e.g., promoting access to services, complex cost containment or improvement
of quality of care), and CM can be applied in different ways in practice, the case
management process offers a practical framework for use with all types of case
management models.
2.3 REQUIREMENTS OF CASE MANAGERS
Case managers play a key role in effective case management practice,
because effective case management relies on the individual case managers having a
high level of knowledge and skills about the overall process of case management.
This section discusses who is most suitable for the case manager role, the
qualifications associated with this position, and the requirements of the case manager
position.
2.3.1 Who is an Appropriate Case Manager?
Case management models of care rely on experienced case managers with
appropriate knowledge and skills to make the case management program effective
(D'Addario, 2002). However, it is sometimes unclear just who is most appropriate for
the role of case manager. Case management has its origins in both social work and
the nursing professions (Gursansky et al., 2003). In the social work literature,
Medicaid and Medicare demonstration projects in the USA employed social workers
to coordinate medical and social services to defined patient populations, such as
people with low income, the mentally ill and the frail elderly. These practices sought
to reduce fraud and ensure efficient use of resources (Austin & McClelland, 1996).
27
In a similar way, the nursing profession was associated with the beginnings of case
management through private duty nursing, institutions and early public health
practices in the USA. Early in its conception, case management itself was linked to
policies of deinstitutionalisation and community care. The need to support clients in
the community highlighted the complexity of the service mix, barriers to access and
lack of continuity in care. The concept of the case manager was thus promoted to
address complex service delivery needs (Moore, 1992), with accompanying complex
issues about the best individual to deal with such demands. Given this background, in
today’s health care market the main contenders for the role of case manager are
nurses and social workers. The ‘nurse versus social worker’ in the case manager role
remains hotly debated. Different authors have put forward arguments as to why each
of these groups should or should not be selected as case managers.
Hallberg and Kristerisson (2004) conducted a review of case management
studies examining care for frail older people. They found that a comprehensive
geriatric assessment seemed the most useful base for case management, and that
nurses have a key role in case/care management for this patient group in particular.
Some scholars also argue that case management practice can be provided most
appropriately by the professional nurse, as this group has a broad scientific
knowledge base, past professional experience, clinical skills, and patient advocacy
commitment (Conti, 1996; Mullahy, 1995; Powell, 2000; Reimanis et al., 2001).
Smith (1995) suggested that nurses in the case manager role are able to provide the
best care to ensure the greatest value and quality for health care funding. Nursing
professionals as a group also recognise the need for changing care models in the
system of health care delivery, and so more and more nurses are being designated as
case managers.
28
Perhaps the most fruitful avenue is to follow the recommendations of Powell
(2000), who argued that assessing the type of population needing case management
is critical when deciding who should act as case managers. For example, there is
evidence that case managers with a social work education are more likely to engage
in crisis intervention, counselling and psychotherapy, but case managers with nursing
education are most likely to engage in discharge activities with clients and utilise
advocacy (Duffy, 2000). Case managers with social work education were more likely
than those with nursing education to use linkage and brokering with clients. Thus
when foster children are the target population, they may best suit the expertise of a
social worker. An older population with multiple medical and social needs may
benefit from the assistance of either a social worker or a public health nurse.
Although there is no consistent answer about which profession is best suited
to be a case manager in the literature, there is growing evidence demonstrating the
effectiveness of nurse case managers. Evidence shows that nurse case management
achieves positive patient outcomes, quality care, and cost-effective outcomes such as
improved client health status, functional status, self-care, shorter hospital stays and
improved client satisfaction with care and money savings (Gagnon, Schein, McVey,
& Bergman, 1999; Schulte et al., 2004; Van Doren, Bowman, Landstrom, & Graves,
2004). In response to these positive results, more and more nurses have been
employed as case managers to service clients in hospitals, the community, or long-
term care institutions.
2.3.2 Nurses and Case Management
The health industry’s focus on case management to bring about coordination
and cost-effectiveness of care has resulted in the creation of a significant job market
29
for nurses (Conti, 1996). A survey conducted in the USA revealed that roughly 63%
of working case managers had a nursing background (American Healthcare
Consultants, 2001). Nursing case management is widely used in many health care
delivery systems, including hospital-based acute care, discharge planning, high cost
disease management, long-term care, chronic illness management and the
management of mentally ill patients (Hallberg & Kristensson, 2004; Lewis, 2005;
Maliski, Clerkin, & Litwin, 2004; Yamashita, Forchuk, & Mound, 2005).
There are two main types of nursing case management in the literature –
‘within-the-walls case management’ (hospital-based acute nursing case management
model) and ‘beyond-the-walls case management’ (community-based nurse case
management) (Cohen & Cesta, 2005b; Huber, 2000). Many hospital-based case
management systems engage registered nurses as case managers. Nurse involvement
in case management allows nurses to influence and direct the delivery and quality of
patient care. This form of case management is the foundation for the development of
the within-walls type of case management. The focus of the case management
services in hospital settings is on the entire episode of care from admission to
discharge, including acute, post-acute, emergency department or other acute care.
Hospital-based case management generally emphasises resource control and
discharge planning functions, whereas community-based case management stresses
client advocacy in finding scarce resources (Cohen & Cesta, 2005b). Many different
types of within-walls case management models are discussed in the literature
(Goodman, 1997; Lewis, 2005; Yamamoto & Lucey, 2005).
Beyond-the-walls nursing case management represents another type of case
management model. This community-based case management is designed to support
patients in achieving the optimal level of wellness by accessing and using
30
community services, especially for vulnerable or high medical cost populations in the
community (Bower, 1992; Faress, 1996; Waszynski, Murakami, & Lewis, 2000). For
example, case management for older adults can screen and identify high-risk clients’
needs and link appropriate resources to improve the quality of life for older people.
Community nurse case management for chronic disease management, the disabled,
older people, or people with mental illnesses has been described in the literature, and
usually has been found to have a positive impact on patient outcomes (Hallberg &
Kristerisson, 2004; Lee & Davenport, 2006; Thompson, Curry, & Burton, 1998;
Yamashita et al., 2005). Case management continues to change nurses’ work in the
marketplace of health care systems. One important influence of the increasing job
market for nurses is the expanding role and education of nurse case managers (Cohen
& Cesta, 2005b).
2.3.3 Nurse Case Manager Roles
Many authors have argued that, in comparison with traditional nursing roles,
nurse case managers focus more on service integration, collaboration with
multidisciplinary teams, integrated delivery networks, innovative partnerships,
strategic alliances, and healthy communities (Conti, 1996; Huston, 2002; Schmitt,
2003; Stolee et al., 2003). Although the case management process is similar to the
nursing process, the focus is much broader in case management. For example, in the
case management process, client assessment is not only undertaken in terms of health
care needs, but also includes the assessment of social and economic needs. In
addition, case management focuses on clients who are at risk, so case selection is
included in the case management process.
31
Case management is a form of health care in which professionals spend much
time working together, often involving collaboration and communication with other
health care providers, which differs from traditional nursing professionals who
normally offer nursing care as an individual nurse. Within the case management
process, more practical work occurs in collaboration and communication with other
professionals and service providers; referrals and monitoring provided services can
be found in the case management process rather than in the nursing process. Hence,
nurse case managers need to be able to successfully act in collaborating,
communicating and negotiating roles, which nurses are likely to lack and need
additional training in the areas. This argument has been supported by the evidence in
the literature (Conti, 1996; Schmitt, 2003) and more specific roles of nurse case
managers have been identified by many authors.
Different practice models or professional environments can be associated
with varied responsibilities or role behaviours demanded of case managers. For
example, Conti (1996) identified 16 roles in the brokerage model of case
management, using qualitative fieldwork from four case managers and survey
methods from 100 nurse case managers. In the acute care setting, Tahan (2005)
identified five role dimensions, namely the clinical care, leadership, financial,
communication, and professional development role dimensions. In the primary health
care setting, Mathunjwa (2000) identified the role of the nurse case managers as
manager, clinical practitioner, educator and researcher. In contrast, Kau and Hsu
(2002) identified nine case manager roles from the nursing literature – clinical expert,
manager of patient care, manager of care quality, coordinator or negotiator,
consultant or advocator, educator, researcher, change agent, risk manager, and
quality promoter. As these examples demonstrate, case managers may have different
32
functions in different case management practices. However, there are some general
functions of case managers that are relevant across all types of case management
models and settings.
The standards of practice for case management in the USA describe four
general case management functions – the case manager as assessor, planner,
facilitator and advocate. In the assessor role the case manager focuses on gathering
relevant information through interviews with the client, the client’s family, or other
members of the health care team. The case manager may utilise formal assessment
tools, telephone assessment strategies, electronic communication, and other efficient
modes of communication as a means to perform evaluation. The planner role
involves performing planning development and prioritisation. In this context the case
manager develops a plan that enhances quality, access and cost outcomes (Case
Management Society of America, 2005).
The facilitator role focuses on communication and collaboration with all
providers to enhance patient care and maximise outcomes. The case manager thus
actively promotes communication between the client/client’s family, members of the
health care team and other relevant parties. The aim is to enhance collaboration
among all parties to achieve stated goals, which are accomplished via coordination of
the delivery of health services to reduce costs and to maximise outcomes. The case
manager engages problem-solving skills and techniques to promote collaboration
among all the service providers (Case Management Society of America, 2005).
In addition, achievement of health and wellbeing is facilitated through
education to prevent risk behaviours and promote positive outcomes. Finally, as an
advocate, the case manager advocates for the services and funding necessary to meet
the established goals. The case manager provides support and education to achieve
33
self-advocacy. The case manager also conducts early referrals to enhance the client’s
access to appropriate, cost-effective services, and enhance the client’s quality of life
(Case Management Society of America, 2005).
To summarise nurse case manager role functions, general case manager roles
are present in all types of case management regardless of the model of case
management used. These roles include assessing, planning, communicating, patient
educating, problem-solving, advocating, collaborating, monitoring, and evaluating.
These roles are presented as embedded in the six steps of the case management
process. These descriptions related to nurse case manager roles can reasonably
support clinical case management. Leadership, problem-solving, communication,
collaboration, and advocacy for clients are likely to be further addressed by nurse
case managers. In other words, nurses are likely to be prepared for and need
additional education in these components. Nurse case managers require additional
education in knowledge and skills related to the case management processes to carry
out these case managers’ functions.
2.3.4 Preparing Nurses to be Case Managers
As the nursing profession adapts to meet expanded job market demands, case
management has created new challenges in the education of nurses (Firn, 1997;
Powell, 2000; Schriefer & Botter, 2001; Schuster, 1997). In order to meet the
demands of the job market place, essential training and education has become
available to help nurses assume their case manager roles. These may concern the
differences between nurse and nurse case manager roles and the preparation or
qualifications that case managers should have. For example, many case management
educational or training programs, such as formal academic courses or in-service
34
education programs have been developed and conducted for nurses (Cohen & Cesta,
2005a; Dreuth & Dreuth-Fewell, 2000; Gallagher & Truglio-Londrigan, 2004;
Howell et al., 2004; Lehna & Tholcken, 2000; Tholcken et al., 2004).
Many authors argue that case manager training and education are key factors
in successful case management in terms of patient outcomes (Barney, Rosenthal, &
Speier, 2004; Cohen & Cesta, 2005a; Conger, 1996; Strodtbeck, Trotter, & Lott,
1998). Increased case manager preparation and training is generally associated with
better care outcomes at reduced costs (Barney et al., 2004; Lancashire, Haddock,
Tarrier, & Baguley, 1997; Stanard, 1999). Comprehensive case management practice
requires professionals with the knowledge and skills to work within existing
bureaucratic and organisational service systems (Smith, 1998). In order to enhance
nurses’ practical performance and prepare them for the role of case manager,
education programs should be offered to help nurses to better meet the demands of
case management practice. Providing education and training in case management
ensures that the registered nurse case manager practices at a competent level of
knowledge and skills, including activities related to case management processes
(Association of Rehabilitation Nurses, 1995).
When examining the type of training and education needed by nurses in order
to prepare them for a case manger role, three different factors will be taken into
account. These are the knowledge required for successful case management, the
relevant skills for case management, and the details of the activities nurses need to be
able to perform for a case manger role. Each of these facets is discussed in detail
below.
35
2.3.4.1 Knowledge Requisites for Case Management
A review of the relevant literature reveals various case management curricula
outlines for providing the knowledge required by nurse case managers. Haw (1995)
conducted a literature review in order to capture the essential elements of case
management education, identifying both background content and basic content
needed in case management training at the undergraduate level. Background content
included definitions of case management, historical perspective on case management,
trends in case management, case management models and case manager roles. Basic
content included case management processes, case management planning, and case
management tools, such as clinical paths and care maps (Haw, 1995).
Another study provided means of identifying the core required content of
case management training. Nolan, Harris, Kufta, Opfer and Turner (1998) asked
twenty acute care case managers to identify the skills and knowledge that would be
of value to nurses new to case manager roles. Knowledge of community resources,
discharge planning, and third party reimbursement were the top three educational
needs identified (Nolan, al., 1998). Powell (2000) also described areas of core
competence for case management training and made recommendations for new case
managers. His key areas for education included case management history, case
management process, case management functions, case management models,
assessment of high risk populations, case management tools, case management
outcome measures, and community resources (Powell, 2000).
The Case Management Society of America has also proposed a series of
foundational knowledge areas for case managers to allow them to function
successfully in their roles. Their recommendations are based on research by Chan
and colleagues (1999), who examined the job activities and knowledge areas deemed
36
essential for effective case management practice. The important knowledge areas
identified included the definition and philosophy of case management, the goals and
objectives of case management, case management processes and tools, assessment,
communication skills, case recording and documentation, negotiation and conflict
resolution strategies, interpersonal relationship skills, community resources and
support programs, legal aspects of case management, health care ethics, and basic
interviewing skills (Chan, Leahy, McMahon, Mirch, & DeVinney, 1999). Table 2.2
provides a summary of the core areas proposed as requisite knowledge bases by these
four main references.
Table 2.2
Essential knowledge areas identified for case management education
(summarised from Haw, 1995; Nolan et al., 1998; Chan et al., 1999; Powell, 2000)
Adopted considerations Case management knowledge topic areas
Haw (1995)
Nolan et al.,
(1998)
Chan et al., (1999)
Powell (2000)
Case management concepts
Definition, History
Trends in case management
Case management purposes
Case documentation
Case management models
Case management tools
Discharge planning; Protocols ;Clinical pathways
Case management processes
Assessment of high-risk populations
Service coordination and referrals
Case management outcome measurement
Community resources
Case management legal or ethical issues
Third party reimbursement
37
All have been deemed appropriate to prepare new case managers for their
roles or in the form of undergraduate level training in case management. Essential
knowledge areas agreed to by at least two sources (see shaded areas in Table 2.2)
include definition of case management, historical perspective on case management,
case management purposes, case management models, case management tools, case
management process, and community resources.
2.3.4.2 Required Case Management Skills
To be successful in a case manager role, nurses need to have certain skills,
enabling them to carry out their clinical and professional responsibilities. Generally,
the essential skills of case managers can be divided into three categories, skills of the
case management process, leadership skills and communication skills (Cesta &
Tahan, 2003). The first of these, incorporating skills required to undertake the case
management process, include the ability to perform comprehensive client
assessments, case management planning, perform client referrals to resources,
implementation of case management plans, monitoring of services and client
outcomes, and evaluation of client outcomes (Cesta & Tahan, 2003; Haw, 1996).
The second group of skills required for successful case management are
various communication skills, which are the lifeline that enables connections
between individuals in any walk of life and in any organisation. Case managers must
master effective communication to be successful with patients, family and the service
providers. These skills include good customer relations, active listening, information
sharing, documentation, collaboration and brokerage (Cesta & Tahan, 2003).
According to Smith’s (1998) study, more effective communication skills (including
collaboration, coordination and interviewing skills), require more attention. Such
communication skills have also been pinpointed as crucial by other authors (Hellwig,
38
Yam, & DiGiulio, 2003; Marino & Kahnoski, 1998; Powell, 2000). Hence,
educational programs need to address nurses’ communication skills in terms of
developing partnerships and interviewing clients and their families.
Finally, leadership skills are important in case management, incorporating
acting as a patient advocate, decision-making, critical thinking, quality improvement,
leadership abilities, networking, partnerships, collaboration, and negotiation. It is
through these skills that case managers are able to be effective in patient care
management, act as team leaders, and to meet the goals of case management and of
the organisation (Cesta & Tahan, 2003; Strassner, 1996). Although Haw (1996) has
identified the leadership as a Master’s level skill, Strassner (1996) argued that
leadership is a required attribute of the case manager role (e.g., advocacy, negotiation,
collaboration, critical thinking, and problem-solving) because they are included in
the common service components of case manager roles (Strassner, 1996).
There is therefore a good case for including basic leadership skills in any
education program that focuses on general case management knowledge and skills.
The essential skills of case management, as emergent from these sources, are
presented in Table 2.3.
Essential skills required by case managers, including case management
process skills, communication skills and leadership skills, help nurses to function in
their case manager roles. This is particularly noticeable in their application of the
clinical case management process, when communicating with clients and their
families, and when taking a leadership role among multidisciplinary groups. These
skills are likely to be enhanced by nurses as they are educated and subsequently
practice as nurse case managers.
39
Table 2.3
Essential case management skills
Case Management
Process Skills
Client assessment
Case management planning
Client referral to resources
Implementation of case management plan
Monitoring of services and client outcomes
Evaluation of client outcomes
Communication skills Developing partnerships with clients and their family
Interviewing clients and their family
Leadership skills Advocacy
Negotiation
Collaboration
Critical thinking
Problem-solving
2.3.4.3 Training for Case Manager Role Activities
Case management can be conceptualised as a compilation of roles and
activities that a case manager performs within a particular health care system. Case
management activities may also be provided to specific populations and communities,
such as the elderly or those with mental health disorders (Goodwin, 1994). Note that
there is little standardisation in the role of the nurse case manager, because
institutions that have implemented case management systems have usually created
their own case manager roles. However, regardless of the care setting, several main
service components and case management activities common to all case management
models can be identified. General case management activities can be identified using
several resources. For example, the standards of practice for case management in
USA describe 24 activities that should be conducted by case managers. Several other
authors have also described activities conducted by case managers.
40
The standards for case management practice refer to “an authoritative
statement agreed-to and promulgated by the practice by which the quality of practice
and service can be judged” (Case Management Society of America, 2005, p. 32). The
standards of performance are relevant to fulfilment of the case manager role.
However, to date there are no standards of case management practice in Taiwan
health care. The Case Management Society of America has established these
standards by drawing broadly across a spectrum of case management practice and
specialties. These activities are related to identification and selection of clients for
case management services, problem identification, planning, monitoring, evaluating,
and outcomes (Cohen & Cesta, 2005b). Each step of the case management process is
associated with a set of activities conducted by the case manager.
Additionally, many other authors and researchers have identified sets of
activities that are conducted by case managers. Tahan (2005) has defined five role
dimensions and related activities involved in case management, including clinical
care, managerial, financial, information management, and professional development.
Under the five dimensions, 27 commonly used role activities describe the case
manager’s job description, functions, and responsibilities. Anderson-Loftin (Flores,
Reyes, & Perez-Cuevas, 2006) developed an instrument describing case manager
role activities. This author identified that activities related to clinical duties and
teaching were the most frequent activities, as assessed using 302 nurses, consisting
of 27 role activities.
Among the common case management activities are several which overlap
with the activities of the nursing process (these include conducting assessment to
identify problem, development of the plan of care, implementation care and
treatment plans, ongoing assessment, reassessment and follow-up). According to the
41
six steps of the case management process, nurses would already be aware of some of
these service components (such as assessment, planning). In order to prepare them
for a further case manager role, those activities that are different to nursing process
activities may particularly need to be addressed during educational programs.
Consistent with the general case manager roles following the case management
process, as described in the previous section, a subset of activities have been
identified as essential case management activities. These selected case management
activities (as listed in Table 2.4) can be seen as the core of case manager practice,
because these activities reflect the processes of case management. The activities
likely to be addressed and provided as training for nurses include communication,
collaboration, advocacy, referrals, monitoring and outcome evaluation of case
management.
Table 2.4
Selected case manager role activities
(adapted from Anderson-Loftin, 1996; Case Management Society of America, 2005; Cohen & Cesta, 2005a)
1. Performing case identification, selection, and outreach functions
2. Identification of actual and potential problems
3. Synthesising assessment information to priorities’ care needs and develop treatment plans
4. Development of the plan of care
5. Implementation of care and treatment plans
6. Communicating with patients, family and revising treatment plans as needed
7. Providing education, information, direction, and support related to care goals of patients
8. Acting as an advocate for the patient and family with service providers
9. Coordinating acquisition of needed resources
10. Performing advocacy and intervention functions
11. Preparing transitional planning an referrals to other health care providers
12. Monitoring and evaluating patient responses to treatment and revising treatment plans as needed
13. Establish measurable case management goals
14. Report quantifiable impact, quality of care and quality of life improvements
42
2.4 THE DEVELOPMENT OF CASE MANAGEMENT IN
TAIWAN
Recent changes in the Taiwanese health insurance system have driven the
central government to set policies to address the economic pressure resulting from
expenditure increases. With the inauguration of the National Health Insurance (NHI)
scheme in 1995, the central government faced a financial crisis when NHI’s annual
expenditure increased faster than its annual income. In response to this situation (and
to prevent medical abuses), in 1997 the Central Health Department of Taiwan
established a three year project to develop discharge planning projects for chronic
illness to encourage patient discharge and reduce health care costs (Lu, Lin, & Wei,
1997). The NHI also promoted the use of disease management to control high
medical costs, including development of clinical pathways. This established the
treatment procedures or protocols for five diseases –tuberculosis, diabetes mellitus,
cervical cancer, breast cancer, and asthma (Bureau of National Health Insurances,
2003) because these identified diseases are likely to have higher health costs.
Currently the Bureau of National Health Insurance provides revenue
according to the quality of care provided by medical institutions. In response, many
medical institutions use case management as a strategy to balance quality care and
cost. Many medical systems develop clinical pathways for high cost cases and use
discharge planning to ensure that chronically ill patients leave hospitals as soon as
possible. Nurses are usually trained as case managers to fulfil their roles as part of
this system. They usually play a coordinator role among multiple health
professionals to conduct clinical pathways and make sure their clients get timely
43
needed quality care. In order to meet this practical trend, case management-related
concepts are increasingly discussed in the Taiwanese literature.
Case management is relatively new in Taiwan’s health care industry, as
compared to other developed countries, and thus is only in the initial development
phase. The introduction of some case management concepts, for example case
management and clinical pathways, first began to be discussed in the late 1990s in
the Taiwanese literature (Lu, Lin, & Wei, 1997). At that time it emerged largely in
the health science literature (Sung, 1998), with a range of different foci. These
included case managers’ roles and functions (Lee, 1999), the application of clinical
pathways in physical therapy (Hsiao & Wu, 1998), the application of case
management in long-term care for the elderly (Kao, 2000), and applying case
management to enhance discharge planning (Lee, 2001). The main goals of this
hospital-based case management aimed to control health care costs and the protocols
focused on treatment. These goals may not suit populations in the community, where
the need is to address primary care and linking people to needed services. This is
supposed to ensure that the vulnerable populations can access appropriate resources
and services. Usually, public health nurses are required to function as case managers
for these populations.
In current Taiwanese practice, case management-related strategies are visible
in many areas of health care, such as social work, nursing, occupational health and
public health. For example, social workers use case management for cases involving
disabled children, abuse cases, people with mental disabilities (Chou, 2000) and
occupational therapists use case management when dealing with rehabilitation cases
(Hsiao & Wu, 1998). However, while some case management models have been
presented in the literature (Chen, 1999; Chou, 2000; Hsiao & Wu, 1998; Sung, 1998;
44
Tai, 2004), most of these are hospital-based models for high cost populations, such
as cancer patients and severely mentally ill patients.
In order to systematically and completely describe nursing case management
in Taiwan, the current situation will be discussed by grouping case management
behaviours into different case management practice settings. These include hospital-
based case management, long-term care case management, and community-based
case management. Case management as used in each of these settings will now be
explored in more detail.
2.4.1 Hospital-based Case Management and Nurse Education
Taiwan has addressed the health insurance policy change reasonably
effectively, and this continues to drive the health care system to balance quality care
improvement and cost control. Many hospitals are meeting the challenge of
socioeconomic pressures and the managed care demands to deliver quality care at
lower costs (Lee, 1999). Under the 1997 project for chronic illness described earlier,
hospitals began to develop and use clinical paths and case management as a strategy
to decrease client hospital days, reduce costs and concurrently maintain care quality.
The goal of the third year of this project (Lu, Lin, & Wei, 1997) was to develop a
case management model and train case managers in the hospital. This work has been
undertaken in only some hospitals.
In order to enable nurses to successfully implement their responsibilities, they
underwent case management training. This training focused on the delivery of care
coordination for clients and their families in hospital-based discharge planning or for
high cost patients, and taught them to collaborate with other professionals (Yang &
Yin, 2002). For example, the Taipei Veteran General Hospital conducted case
45
management training for 81 nurse case managers, and developed case management
models for women with gynaecological cancer, neurological patients, children with
chronic illnesses, and individuals diagnosed with schizophrenia (Feng, 2002; Hsieh,
2003; Yang & Yin, 2002).
Published articles have revealed the initial positive effects of these hospital-
based case management projects in terms of cost benefit and quality of care for
patients with stroke and total hip joint replacement patients (Liao & Lu, 2000; Lin,
2000). Unfortunately, few of these articles describe in detail how the nurse case
managers were educated. The Taipei Veteran General Hospital does mention that
nurses were trained as case managers through in-service training with 24 contact
hours and clinical training for one year. Accessing the training material, however,
was difficult as the training was conducted by this hospital for its own nursing staff
and was not available to other interested parties.
2.4.2 Long-term Care Case Management and Nurse Education
Taiwan has recently seen a surge in long-term care systems because the
growth of the ageing population is a major factor contributing to the high cost of
health care (Long-term Care Association of Republic of China, 2001). These
resources are, however, scattered between the medical health system, the social
welfare system, and public or private institutions. It is difficult for the older
population to locate updated information and access these services. In order to ensure
that older adults can receive necessary services, and provide respite to their families,
the central health department developed a project known as the ‘Long-term care for
the elderly three year planning project from 1998’ (Health Department of the
Executive Yuan of Republic of China, 1998). The main goals of this project are to
46
build an integrated service network and to set up a long-term care managed centre in
each county of Taiwan. Twenty-five long-term care managed centres were
established by 2003 (Long-term Care Association of Republic of China, 2001). Their
services include linking, coordinating and developing resources for clients and their
families, and is aimed at individuals whose Barthel Index score is under 75. The
Barthel Index is a tool to measure an individual’s functional status. It includes seven
items addressing self-care and three items addressing mobility. The Barthel Index
identifies low, middle and high degrees of dependence, with a score under 75
meaning the individual is dependent to a middling degree.
The long-term care systems established in Taiwan apply the managed care
model, offering services through managed care centres in each county. Each centre
consists of at least two case managers, one from social work and the other from
nursing. Although this model is also called community-based long-term care
management, it is different from the community-based case management undertaken
by the public health nurses in the community health centres. These long-term care
centres do not care for patients with mental illnesses or actively approach older
adults living alone in the community. These centres only offer services to older
people with intermediate level disabilities and their families.
The case managers who work in the long-term care managed centres are
trained through case management courses run by the Long-term Care Association of
the Republic of China. The main roles of case managers include needs assessment,
planning and coordination, service management, service monitoring, resource
development, and offering information (Chen & Li, 2001). The association runs an
annual continuing educational seminar for the case managers in each centre and
those staff working in long-term care institutions. The training topics focus on
47
managed care in long-term care or resource integration and utilisation, such as
managed care in the application of long-term care, the development and linkage of
social resources, and communication skills. However, the training is usually held for
three days and is specifically for those engaging in long-term care. It is not easy for
other nurses, such as public health nurses, to access this education.
2.4.3 Community-Based Case Management and Nurse Education
Community case management has also been applied in Taiwan, as the health
care policy of Taiwan has shifted from hospital-based care to community-based care.
However, community case management models have not yet been developed or
established in Taiwan (Tai, 2004). The Taiwanese government has established a plan
to build a community-based medical care system over five years, running from 2003
until 2008. In response to this policy, the Taipei City Government has used case
management strategies to offer needed services for vulnerable populations of
mentally ill patients and older adults living alone in the community. This new way of
using case management challenges public health nurses to meet the demands of
changing health care delivery methods.
Public health nurses are usually experienced registered nurses employed in
the health stations of each district in Taiwan. These stations became health service
centres in 2005 (Department of Health Taipei City Government, 2005). Public health
nurses play a critical role in the community by offering primary, secondary and
tertiary care for all those living in the community. They have engaged in health
promotion and case management from 2005. Traditionally they offer direct care for
clients with a chronic diagnosis and provide services independently. Recently their
role has shifted to one that identifies those at high risk, clients with a high utilisation
48
rate, and vulnerable populations (including patients with mental illnesses and older
adults living alone), and also providing links to needed services. Public health nurses
act as case managers, focusing on communication, coordination, and cooperation
with other professionals (Tai, 2004).
So just what is required of public health nurses in their role as case managers?
Their target groups are older adults living alone and mentally ill patients. For older
adults living alone, public health nurses in each health centre are responsible for
developing and conducting health management and referral to needed services for
clients (Taipei City Government, 2003). For mentally ill patients, public health
nurses act as case managers involved in monitoring them, referring them and
following up to relevant resources. However, these public health nurses usually have
little training and education in relation to case management for mentally ill patients
because of the new responsibilities for public health nurses to manage this population
beginning in 2005.
Given these changes in community case management, traditional community
nurses’ roles cannot meet the new health care delivery systems. Public Health nurses
now need to use multiple strategies, such as assessment, planning, identifying
resources, coordinating, linking and evaluation, to achieve positive patient outcomes.
They need more information about community resources, screening and identifying
at risk populations in the community, and new communication skills to collaborate
with multiple professional groups. Unfortunately, to date there is no systematic case
management education program offered for public health nurses to prepare them to
be case managers. Thus public health nurses require particular support and
professional education to meet this new case management challenge.
49
2.4.4 Differences between These Three Case Management Programs
Among these three current case management practices in Taiwan, several key
differences can be identified. Firstly, as these programs are conducted in different
settings (hospitals, managed care centres, the community), the features of the target
populations are different in each of these settings. In hospitals, the client’s risk and
health problems are more complex or associated with higher costs than in managed
care centres. The community populations generally have better functional status and
the focus is usually on prevention or maintaining care. A second difference between
these approaches is their practice contexts. The practical aspects of community-based
case management focus on a brokerage model (linking needed resources) rather than
a full service model or long-tern care case management. Finally, the roles of case
managers are also different across these settings. The main role of public health
nurses involves linking needed resources to clients, specifically for the older
population, those on low incomes, and mentally ill patients. In contrast, case
management in hospitals is focused on balancing cost and quality of care. Across the
three case management programs, public health nurses particularly need additional
education in relation to case management, because few educational opportunities are
offered for them to prepare for their changing practice of case management work.
2.5 PUBLIC HEALTH NURSES’ PREPARATION FOR CASE
MANAGEMENT
This section explores why public health nurses (PHNs) require better
preparation and education for case management practice, describes this nursing
population, and places this problem in the particular context of the conditions in
Taiwan.
50
2.5.1 Rationale for Preparing PHNs as Case Managers
There are several reasons why public health nurses need to be educated for
their case manager role. First, the health care system is changing; particularly in the
way it uses case management as a care delivery method, thus requiring nurses to
develop new skills to meet these demands. Traditional nursing roles are not adequate
for the expanding new case manager roles. In moving from a caregiver role to that of
a case manager role, public health nurses need to be supported and trained. Schmitt’s
(2003) study described the experiences nurses in their role transitions from caregiver
to case manager. As new case managers, nurses desired and benefited from guidance
and support from more experienced and knowledgeable mentors. Continuing
professional education is effective for professionals undertaking novice to expert
transitions (Schmitt, 2003).
Secondly, in order to ensure improved effectiveness and positive patient
outcomes, specific case manager training is a key element for success (as described
earlier). To ensure case management successfully impacts on patient outcomes, the
case manager must have extensive training and ongoing continuing education.
Unfortunately, many Taiwanese public health nurses develop and perform in their
case management role with little or poor training, because there is no prior academic
preparation and limited continuing education programs offered for them.
Finally, the educational background of public health nurses may be not be
sufficient for them to meet the requirements of their role. Marzke (1995) conducted a
survey of 121 case managers and found that most case managers’ abilities and
confidence came from continuing education, rather than prior educational
preparation or training. The findings of this study support the argument that PHNs
require additional continuing education to enhance their abilities and confidence as
51
case managers. However, in Taiwan, there are few educational programs available to
provide public health nurses (PHNs) with the essential knowledge and skills to
function in the role of case manager demanded of them. These factors have prompted
nursing educators to consider possible solutions to the current crisis. Many
researchers are calling for the development and delivery of a systematic case
management education program for public health nurses/case managers in Taiwan to
meet these emergent educational needs (Lee, 1999; Lee, 2000; Yang, 2003).
2.5.2 Educational Needs of PHNs in Taiwan
There is general agreement that it is important to identify training and
educational needs of PHNs (Anderson, 2001; Gould, Kelly, White, & Chidgey,
2004), as an educational needs analysis is the initial step in a cyclic process that
contributes to the overall training and educational strategy of staff in a professional
group (Gould et al., 2004). The cycle commences with a systematic consultation
designed to identify the educational needs of that population, followed by course
planning, delivery and evaluation (Gould et al., 2004). In addition, an educator
requires certain information to develop learning activities that are appropriate for the
learners (O'Loughlin, 2002).
Needs assessment refers to the identification of the learning needs of the
target populations and how those needs will contribute to an overall strategy of
training and education (Furze & Pearcey, 1999). Needs assessment usually implies a
data gathering and interpretation process through which learner needs are identified,
assessed, and used to develop learning activities and materials (O'Loughlin, 2002).
The literature describes many different methods of conducting a needs assessment,
including using an expert panel, focus group discussions, individual interviews and
52
surveys using questionnaires (Anderson, 2001; Chevannes, 2002; Nash, 2002). One
continuing educational needs assessment for public health nurses in Taiwan was
conducted using an expert panel (Lee, 1999). The results revealed that case
management theory/practice was the second-highest priority of the nine areas of
community health care practice identified as most important in the 21st century,
according to practitioners, officials and scholars. This strongly suggests that
Taiwanese public health nurses need continuing education in case management (Lee,
1999).
Educational needs in this context constitute the gap between an existing level
of knowledge and skills and the level required for effective performance. Education
or training is perceived to be the means of closing the gap between current behaviour
and desired behaviour (O'Loughlin, 2002). The gaps in PHNs’ current knowledge
and the exact content knowledge required for these public health nurses need to be
identified. However, little work has been undertaken to date to explore public health
nurses’ educational needs in case management. In addition, there is no available data
about the current practice of public health nurses in Taiwan. In subsequent chapters
the means to address this gap will be discussed. Once the educational needs of the
public health nurses have been established, it will be necessary to identify effective
strategies for educating Taiwanese public health nurses in case management. This is
addressed in the following section.
2.5.3 Strategies to Prepare PHNs for Case Management
In any area of employment professional development is necessary. Public
health nurses particularly need tailored professional development courses because
there has been a shift in the role of public health professionals, with the result that
53
many need to update their knowledge and skills. Continuing education is needed to
deliver the training to this widely dispersed workforce (Gebbie & Hwang, 2000).
There is evidence that continuing professional educational programs are successful in
producing changes in the knowledge, skills and practice of nurses (Barta & Stacy,
2005; Davila, 2006; Robertson, Umble, & Cervero, 2003; Yeh et al., 2004). Based on
this rationale, a case management continuing education program for public health
nurses needs to be developed and evaluated for its impact on PHNs’ knowledge,
skills and performance.
How should this education program be conducted? In the special context in
Taiwan, most public health nurses may not have educational preparation in case
management and most faculty members in schools of nursing lack experience in the
case manager role. This suggests that information about nurses’ experiences of their
case manager roles would provide useful information for the nursing academics who
tend to construct and deliver case management education for nurses (Schmitt, 2005).
For this reason, collaboration between nursing academia and clinical nurses may be
the best strategy to prepare nurses for their expanding roles.
There are many benefits of collaborations between nursing academia and
practice. Firstly, standardised education and increased participation in programs
tends to result in significant cost savings to institutions, decreased training
investment by employer institutions or hospitals; and good relationships, shared
knowledge and expertise. In addition, academic programs influence health care
delivery within the local community and open lines of communication between
academia and services, as well as providing increased opportunities to develop joint
educational programs and seminars for staff and faculty enrichment and ongoing
learning (Gursansky et al., 2003; Nalle et al., 2001).
54
Collaboration between nursing academia and nursing practice appears to be
the new trend within continuing education (Cervero, 2000; Knox, 2000). Through
collaboration, nursing academics and those engaged in clinical practice can work
together and cooperate through establishing partnerships, setting mutual values and
goals, and sharing responsibilities, resources and accountability (Friend & Cook,
1996; Springer, Corbett & Davis, 2006). Available literature suggests that such
collaboration can link learning to clinical practice and greatly enhance positive
educational outcomes (Morrison, Stone, & Wilson, 2005; Robertson et al., 2003). A
number of authors have recently recommended collaboration between academia and
practice on the basis of their own successful experiences.
Collaboration between academia and nursing practice can be beneficial and
enhance the application of evidence-based practice (Papenhausen et al., 1999;
Springer et al., 2006). Papenhausen and colleagues (1999) conducted a collaborative
implementation of service-academic partnerships and recommended that the benefits
included increased ability of academic programs to influence health care delivery
within the local community, open lines of communication between academia and
service providers, and increased opportunities to develop joint educational programs
and seminars for staff, and faculty enrichment and ongoing learning (Papenhausen et
al., 1999). In addition, Mayer (2000) developed a continuing education program
which involved collaboration between academics and clinical nurses, and fostered
innovation and cooperation in practice, education and research. Springer and
colleagues (2006) described their experience of developing a collaborative model
between a university and a medical centre. The aim of this program was to enhance
nurses’ knowledge and skills in order to achieve evidence-based practice. Hence,
collaborative continuing education between public health nursing practice and
55
(nursing) academia might be considered an effective strategy to meet Taiwanese
public health nurses’ emergent case management education needs.
2.6 SUMMARY
Today case management is evident in almost every area of health care, and
nurses comprise the majority of case managers in these systems. Case management
can be seen as a process including case selection, assessment and needs identification,
planning and resource identification, service implementation and coordination,
monitoring service delivery and evaluation of patient care outcomes. During this
process, nurse case managers are engaged in assessing, planning, educating,
negotiating, monitoring, problem solving, advocating, collaborating, and evaluating –
regardless of the type of case management model being implemented. Nurse case
managers need a set of essential knowledge and skills to allow them to successfully
undertake their case management roles. In this chapter these essential knowledge
bases, skills and role activities have been identified from the literature, but further
assessment is needed to confirm the specific educational needs of nurses employed
as case managers in the Taiwanese context. These issues can then be addressed in the
continuing education program.
In Taiwan, one area in which case management has been applied is in the
community, and public health nurses in these centres are generally required to act as
case managers. For this role they need to be prepared with the essential knowledge,
skills and role activities of case management described above. In this way a case
manager’s educational preparation is the key for successful case management.
Taiwanese public health nurses, however, are in a particularly vulnerable position
because few case management education programs are provided for them. Hence
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there is a clear gap between nursing education and case management practice in
Taiwan. Collaboration between public health nurses and nursing academics is a
possible strategy identified in the literature. The collaboration would involve
establishing partnerships, setting mutual values and goals, and sharing
responsibilities, resources and accountability in collaborative continuing education
program. Public health nurses can then share their experience with other colleagues
in case management practice and work with the nursing academic to learn case
management practice. The next chapter will review and discuss existing methods of
continuing professional education in case management. The applicability of different
approaches to the public health nurse context in Taiwan will be evaluated.
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CHAPTER THREE
LITERATURE REVIEW ON CASE MANAGEMENT
EDUCATION
Education is an essential element for the successful implementation of any
case management approach. This chapter describes continuing professional education
(CPE) related concepts, including evaluation of CPE, the effectiveness of CPE and
identification of the factors influencing the effectiveness of CPE. Existing case
management education programs and recent evaluations of case management
continuing professional education programs will be reviewed.
3.1 CONTINUING PROFESSIONAL EDUCATION
Being a health care profession, CPE is required for nurses to update their
current knowledge and maintain clinical competence in order to meet rapid changes
within health care systems (Underwood, Dahlen-Hartfield, & Mogle, 2004). CPE has
been described as a means of facilitating better quality care and patient outcomes
through professional development, which is the lifelong process of active
participation in learning activities to enhance practice (American Nurses Association,
2000). This section reviews the evaluation of CPE, the effectiveness CPE and factors
influencing effectiveness.
3.1.1 Evaluation of CPE
There are many ways of evaluating the effectiveness of an education program,
and many different reasons for doing so. For instance, organisations need to balance
the cost and results of delivering educational programs, quality assurance may be
58
concerned with course process evaluation, but participants may be more concerned
with outcome evaluations or aims achieved. In order to demonstrate that a course
provides value in terms of personal and professional development, and as a way to
judge its effectiveness, course evaluation has become a critical component of
education. Nurse educators have always placed students at the forefront during
course evaluation in an attempt to establish levels of satisfaction, to test for
performance and acquisition of knowledge, and to determine attitude change (Gould,
Kelly, White, & Glen, 2004). Hence, various approaches to the evaluation of
continuing education programs have been described in the literature.
There are many evaluation models of CPE, each with specific features and
foci. Abruzzes’ (1996) and Kirkpatrick’s (2006) evaluation models focus on the total
program in terms of process, content, outcome and impact evaluation. Hawkins and
Sherwood (1999) have developed a pyramid evaluation model using five levels to
measure the overall effectiveness of CPE, including examining the goals, reviewing
program design, monitoring of program implementation, assessing outcomes and
impact, and undertaking an efficiency analysis. Koyama and colleagues’ (1996)
model considers the inputs, processes and outcomes which enable the CPE evaluator
to look at CPE program planning, implementation, and evaluation. Similarly,
Stufflebean’s (1983) educational evaluation model includes four types of evaluation:
context, input, process and product.
Although all these models appear to vary in their evaluated outcomes, several
share similar features that measure multiple levels of outcomes, including process
evaluation, content evaluation, outcome evaluation and impact evaluation (although
these are often labelled differently). In addition, several models address the three
aspects of the CPE, namely input, process and outcome, to comprehensively consider
59
the planning, implementation and evaluation of the program. In terms of the research
design, there is also a need to consider independent factors influencing the
effectiveness of CPE. Hence, when conducting a comprehensive and integrated
evaluation of the effectiveness of CPE, all three of these issues need to be considered,
namely multiple levels of evaluation, factors influencing effectiveness, and the whole
picture approach (input/process/output). However, these five evaluation models
discussed above fail to consider all these aspects in guiding the development,
implementation and evaluation of programs. Hence, there is a need to further
synthesise evaluation models of CPE in order to provide an integrated measure of the
outcomes of education programs.
As noted earlier, these models share some similarities in that they all account
for four levels of evaluation. These are process evaluation (labelled as Level I –
reaction evaluation), content evaluation (Level II – learning evaluation), outcome
evaluation (Level III – performance evaluation), and result evaluation (Level IV –
impact evaluation). These four levels of evaluation identified from existing
evaluation models will guide the review of current studies of CPE in case
management, and thus are described in detail in the following section.
3.1.1.1 Level I: Reaction Evaluation
Level I represents a reaction evaluation, the most formative type of
evaluation, by providing information or feedback during the implementation or after
the educational program (Stufflebean, 1983). Reaction evaluation has been called a
‘happiness index’ and involves the participants’ immediate reaction to the program.
It assesses the effectiveness of the teaching and learning methods, content relevance,
and appropriation of the physical facilities (Abruzzese, 1996). According to
Kirkpatrick (2006), reaction evaluation is related to process evaluation, and evaluates
60
the learners’ satisfaction with the CPE program. The basic question of this level is,
‘were the participants satisfied with the program?’. The reaction evaluation provides
valuable feedback on a course and also provides quantitative information about the
training. It can be used to establish standards for later courses (Kirkpatrick, 2006).
Hence, reaction evaluation was measured in the current study.
3.1.1.2 Level II: Learning Evaluation
Level II of evaluation of CPE is learning outcome evaluation, which
determines if the learners have achieved the object of the CPE (Abruzzese, 1996;
Kirkpatrick, 2006). Learning is “the extent to which participants change attitude,
improve knowledge, and/or increase skills” as a result of attending the program
(Kirkpatrick, 2006, p. 22). In order to effectively evaluate learning, the training must
have a specific objective against which evaluation can be conducted. Measuring
learning is more difficult and more time-consuming than measuring reaction
(Kirkpatrick, 2006) and such learning measurements should be objective and
quantifiable. Learning evaluation measures the degree to which participants have
learned the information imparted during the educational experience (Abruzzese,
1996). It is linked to acquisition of knowledge and skills, and attitude change.
Kirkpatrick (2006) puts forward a series of guidelines for evaluating learning that
include using two groups (a control group and an experimental group) and evaluating
changes in the knowledge level or skills of the trainee. Changes can be measured
using pre- and post-tests. Knowledge and skills are easily evaluated by paper- and
pencil style tests, and it is best to evaluate everyone involved in a training programs.
However, even though a person may learn something during a program, it does not
mean that he/she will apply that learning, or that it will affect the overall operation of
61
the organisation. This factor leads to the next two levels of evaluation. Learning
evaluation was thus assessed in the current study.
3.1.1.3 Level III: Performance Evaluation
Level III is known as performance evaluation, and focuses on changes in
learners’ performance after a CPE program (Abruzzese, 1996). Performance
evaluation is linked to a change in practice by the learner. This evaluation is the same
as Kirkpatrick’s behavioural level. The questions posed at this level establish
whether (and how) training has affected job performance. Questions asked are, ‘did
the participants change their behaviour based on what was learnt?’ and ‘has the job
performance of the trainee improved because of the training?’ (Kirkpatrick, 2006).
Evaluation at this level is more complex than at the learning or reaction levels.
Nevertheless, Kirkpatrick suggested it should be built into any training program.
Surveys and interviews are effective means of evaluation at this level (Kirkpatrick,
2006). Hence performing evaluation was measured in the current study.
3.1.1.4 Level IV: Impact Evaluation
Level IV refers to impact evaluation, and is the level linked to the ultimate
quality of the service. This evaluation is a result-level evaluation focusing on the
impact of training on an organisation or in terms of patient outcomes. Evaluation at
this level is very important, but also very difficult to accomplish. Changes in any
organisation occur with or without training, and isolating the effects of training is not
always easy (Kirkpatrick, 2006).
Although all educational programs ideally should measure all four levels of
outcomes, time and practical limitations in the current study (as in most studies)
restrict the opportunity to undertake impact level evaluations. The Taiwanese
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community authorities had not previously established a standard case management
practice, thus there were no existing benchmarks available for comparison. This
study was unable to measure the impact of the developed educational program on
patient outcomes. Hence, the present study assessed only three levels of outcomes:
reaction, learning and performance outcomes.
Several studies have examined the relationships between these four levels of
evaluation. Results reveal that reactions (Level I) to training are not related to any
other target of evaluation (Alvarez et al., 2004; Kraiger, 2002; Tannenbaum et al.,
1993) but learning (Level II) is significantly correlated with performance (Level III)
and results (Level IV) (Holton, 1996; Kraiger, 2002; Sekowski, 2002; Tannenbaum
et al., 1993). Many authors have argued that the distinction between training
effectiveness and training evaluation is important (Alvarez et al., 2004; Sekowski,
2002). Research into training effectiveness seeks to determine what factors influence
the effectiveness of the program, or explores the relationships between these four
levels of evaluation. The current study addressed educational evaluation rather than
educational effectiveness. Hence, the relationships between these four levels of
evaluation will not be examined in the current study.
No single evaluation can provide a complete understanding of the
effectiveness of a program, thus many evaluation models use multiple level
evaluations within CPE. These approaches usually use a mixed methods technique,
employing both quantitative and qualitative data collection methods. This is
especially true in educational program evaluation, in which multiple level
evaluations with mixed methods offer a broad base upon which to judge the
effectiveness and value of programs (Johnson, 2004). For example, a study by
Lazarus and colleagues (2002) used mixed methods to evaluate program attendees’
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concerns related to cost, access and quality of the presentations. Their findings
provided a great deal of insight into the effectiveness of the program and allowed
recommendations to be made (Lazarus, Permaloff, & Dickson, 2002). Hawkins
(1999) has also presented an integrated approach for evaluating continuing education
programs and outcomes, which combined both quantitative and qualitative data
collection methods. This author argues that a mixed methods approach is important
because qualitative data can give context, richness, and meaning to the
accompanying quantitative data.
It is clear from this and other sources that qualitative inquiry, particularly the
use of focus groups, can be very helpful in determining the effectiveness of a training
program, in terms of changes in attitudes and beliefs, skills acquisition, and changes
in practice. Evaluation questions addressing these issues could include, ‘What skills
have you acquired as a result of the program?’, and ‘Have you changed the way you
practice nursing since attending the program? If yes, how has your practice changed?
If not, why not?’ Using this method is one means of addressing the difficulties of
measuring the effect of a continuing education program, as described in the previous
section (Hawkins & Sherwood, 1999).
3.1.2 Effectiveness of CPE
The importance and relevance of continuing professional education for nurses
and patients has been repeatedly asserted in the literature (Adami & Kiger, 2005;
Bibb et al., 2003; Bierema & Eraut, 2004; Cervero, 2000; Spollett, 2006; Underwood
et al., 2004). CPE for nurses continues to be a viable means of maintaining
competency and achieving better quality care and positive patient outcomes in health
care settings (Underwood et al., 2004). The literature identifies the effectiveness of
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CPE in a variety of spheres. For the current discussion the impact of CPE is
discussed in two different sections, first in terms of its impact on nurses’ knowledge
and skills, and then in terms of its effect on nursing practice and patient outcomes.
3.1.2.1 Impact on Nurses’ Knowledge and Skills
The value of continuing education for nurses has been demonstrated on
several occasions (Berarducci, Lengacher, & Keller, 2002; Brunt, 2000; Chang et al.,
2002; Yeh et al., 2004). Many empirical studies have shown that CPE has a positive
impacted on nurses’ knowledge and skills (Berarducci et al., 2002; Davila, 2006;
Goudarzi, Tefagh, Monjamed, Memari, & Kamali, 2004; Huang et al., 2002; Yeh et
al., 2004). Wood (1998), in a review of the nursing literature on the effects of
continuing education, concluded that nurses consistently identified as having
increased confidence, improved knowledge and increased self-awareness.
However, some authors have argued that improving nurses’ knowledge
cannot be the real value of CPE, because institutional providers may be more
interested in practice change or the performance of their staff (Furze & Pearcey,
1999; Griscti & Jacono, 2006; Wood, 1998). However, recent empirical research has
still focused on demonstrating the effect of CPE on nurses’ knowledge and skills
(Dickerson & Mansfield, 2003; Goudarzi et al., 2004; Huang et al., 2002; Sen, 2005;
Stolee et al., 2003), because updated knowledge and skills help nurses to meet their
changing work environment and maintain their work competency.
Nurses are encouraged to update their knowledge and maintain clinical
competence, especially in the light of the rapid changes currently taking place within
health care systems (Griscti & Jacono, 2006). Knowledge and skills are crucial
because they enable the nurse to deliver innovative care models, advanced practices,
new roles and improved quality of care. According to Manley (1991), nursing
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knowledge also improves nurses’ professional status, in that the knowledge and skills
attained through CPE are utilised to enhance both their recognition by other health
care professionals and their ability to deliver high quality care. In terms of case
management in particular, Kulbok and Utz (1999) argued that knowledge and
educational preparation are important strategies to prepare nurses for existing and
evolving case management roles. Howell (2004) also stated that essential knowledge
and skills are needed for enhancing a new role, such as that associated with case
management. This is especially true for nurses who become case mangers, as they
have identified knowledge and skills as increasing their ability and confidence to
function in their case manager role.
3.1.2.2 Impact on Nursing Practice and Patient Care
Not only knowledge and skills themselves, but also practice can be positively
affected by CPE. Several published research studies reported clinical practice
changes (along with an increase in knowledge and skills), as outcomes of continuing
education programs. Hence, direct impacts on nursing practice are another benefit
from the continuing education program process and need to be discussed.
Numerous studies provide support for the claim that CPE improves nursing
practice and patient care (Adami & Kiger, 2005; Clarke, Abbenbroek, & Hardy,
1996; Czurylo, Gattuso, Epsom, & Stark, 1999; Dickerson & Mansfield, 2003; Ger et
al., 2004; Huang et al., 2002; Wood, 1998). Improvements that have been recorded
include appropriate nursing interventions, improved nurse performance, more
confidence in practice, better quality of patient care, perceived preparation for case
management role, better care planning and more frequency in needed skills and
service activities.
66
For example, Clarke’s (1996) study demonstrated that the implementation of
appropriate treatment improved by 30% following the introduction of CPE. Research
by Ger and colleagues also revealed significant to moderate improvements in nurses’
practice (in terms of pain assessment using pain rating scales) after attending a
continuing education program (Ger et al., 2004). Waddell (1991) conducted a meta-
analysis of 34 published studies examining the causal relationship between CPE and
nursing practice. Waddell concluded that 75% of those who participate in CPE will
deliver improved care on their return to the work environment. The perceived
positive impact of CPE attendance was even higher, at 90% (Hutton, 1987; Waddell,
1991). Hughes (1990) utilised a qualitative methodology to explore how CPE may
impact on the quality of patient care. The results showed that all the attendees agreed
that the course had influenced the delivery of individual patient care. Wood’s (1998)
review supported the need for education to inform and influence the development of
nursing practice and thereby improve the delivery of patient care (Wood, 1998).
It is important to understand how these practice changes come about. Keiener
and Hentschel’s survey revealed that 51% of the sample of 443 nurses identified new
knowledge as a facilitating factor for practice changes (Kiener & Hentscel, 1992).
Another study which incorporated a follow-up evaluation after continuing education
found that 91% of nurse respondents stated that they had an opportunity to use the
new information provided. Of those who used the information, 98% stated the use of
this information had improved patient care (Czurylo et al., 1999). This data suggests
that the acquisition of knowledge and skills is essential in that it then allows nurses to
establish better quality of care and patient outcomes.
Several studies have been conducted to evaluate whether CPE improves
nursing practice or patient outcomes. Some evidence supports the use of CPE in
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nursing practice and patient outcomes (Clarke et al., 1996; Dickerson & Mansfield,
2003; Kingston, 2001; Sterman, Gauker, & Krieger, 2003; Valaitis, 2002). For
example, Valaitis reviewed 32 studies that compared an intervention group who
received continuing education with a control group. This paper concluded that
continuing education activities can improve professional practice and patient
outcomes (Valaitis, 2002).
Many authors support the need to measure the effect of CPE on patient
outcomes, rather than in terms of its influence on nurses. However, the decision was
made that this study would not measure patient outcomes, simply because this would
require too many external factors to be controlled (Ellis, 1996). Many evaluation
studies fail to report the reliability and validity of the instruments used to measure
the effects of education on practice (Ellis, 1996). As Jordan points out, practical,
ethical and budgetary difficulties, such as an increased risk of the Hawthorne effect,
are potential pitfalls when attempting to measure changes (Jordan, 2000). Many
existing studies evaluating the impact of CPE on patient outcomes lack appropriate
research design and control of external factors. For example, Valaitis’ review of 32
studies measuring the effect of health professionals’ behaviours found that almost all
the target behaviours involved learning a fairly complex set of skills, and in general
studies had poor reporting of the methods used (Valaitis, 2002).
In the case of the initial delivery of a case management approach, many
external factors can affect patient outcomes. Ellis argued that the control of variables
in relation to the individual nurses being studied, their practice area, their patient
caseload and the CPE program undertaken are but a few of the problems (Ellis, 1996).
In Taiwan, there is no standard case management model or procedures in each health
centre, and PHNs have different caseloads. An added difficulty is location, in that
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public health nurses usually conduct home visits. These types of practical issues
make it difficult for the current study to evaluate the impact of a program on patient
outcomes. Thus there is a high level of complexity when attempting to measure the
effect of continuing education on nursing practice and patient outcomes. Such
difficulties are heightened for those researchers developing new delivery methods.
3.1.3 Factors Influencing the Effectiveness of CPE
Although, as described above, there are many benefits associated with
continuing professional educational programs, the effectiveness of CPE can be
affected by a range of factors. The study of factors that influence the educational
process, outcomes and performance is known as educational or training effectiveness
research (Alvarez, Salas, & Garofano, 2004; Sekowski, 2002). Three categories of
influencing factors are identified in the literature: individual factors, training factors
and organisational factors (Alvarez et al., 2004; Cervero, 1985; Griscti & Jacono,
2006; Holton, 1996; Kruijver, Kerkstra, Franke, Bensing, & Wiel, 2000). Cervero
(1985) has put forward a model identifying four sets of independent variables to
explain performance changes resulting from attendance at a CPE program, namely
individual factors, the CPE program, the proposed behaviour change, and the social
system in which the professional operates. Kruijver and colleagues (2000) also
generated a set of variables which they argued could influence CPE, based on their
review of 14 CPE program studies. They highlight participant characteristics,
program characteristics, and social system as factors influencing CPE. More recently,
Griscti and Jacono reviewed the effectiveness of continuing education programs in
nursing, concluding that individual, professional and organisational perspectives
were factors that facilitated the implementation of continuing education in nursing
(Griscti & Jacono, 2006). Using this literature as a base, the influencing factors are
69
discussed here in terms of individual factors, educational factors, and organisational
factors.
3.1.3.1 Individual Factors
The first category of factors is individual characteristics, which incorporates
features such as demographics, clinical experience and prior training. The
relationships between individual characteristics and program effectiveness remain
unclear. Merriam and Brockett (1997) identified a series of demographic factors that
limit access to adult education. For example, they found that age and gender
influence who participates and who does not participate in educational opportunities.
Younger adults often continue learning for their jobs, but older adults tend to have
lower levels of education than younger people.
In addition, Kruijver and colleagues (2000) highlighted participant factors
such as work setting, discipline, and work experience as important variables, using
their review of continuing educational studies. At the performance level, Flores and
colleagues (Green, 2001) explored the influence of physician factors on the
effectiveness of a continuing education intervention. The results revealed that factors
triggering positive changes included receiving the educational intervention, having
less than 16 years of clinical practice and receiving continuing education in the past
year. In addition, a participant’s level of education is a good predictor of who will
continue to participate in educational activities. There is evidence that education
level is positively related to the knowledge level of individuals (Melnyk, Fineout-
Overholt, & Feinstein, 2004). These studies suggest that individual characteristics
can influence the effectiveness of educational intervention.
Motivation is another complex factor influencing the effectiveness of training
and education. Motivation often appears to be treated in the literature as an
70
intervening variable between educational intervention (the independent variable) and
effectiveness (the dependent variable). A study by Green explored the relationships
among individual characteristics, work environment characteristics, learning and job
behaviour (National Institute for Occupational Safety and Health, 1999). This study
confirmed that participants’ reactions to education programs moderate the
relationship between learning and job behaviour. The author also suggested that the
education program designer and instructors need to spend ample time designing and
delivering a training program that produces positive reactions. If the participant is
motivated to learn, a positive reaction to training will help increase the likelihood
that learning will occur. In educational research, motivation to learn is one variable
that often cannot be meaningfully observed, manipulated, or measured. Random
selection and assignment of subjects are presumed to control for most intervening
variables (Goldstein & Ford, 2002). Some studies have demonstrated significant
support for the relationship between pre-training motivation and educational
effectiveness (Cervero, 1985; Tracey, Hinkin, Tannenebaum, & Mathieu, 2001).
Hence, enhancing participants’ motivation for learning needs to be considered in
program design and the use of a randomised design can overcome the effect of
variables such as motivation when measuring the effectiveness of a CPE program.
These studies suggest that a series of different individual factors can
influence educational effectiveness. The most notable of these are age and prior
educational and work experience. Thus in the development of the current study these
participant factors will be assessed. The specific variables relevant to the population
of public health nurses will thus be age, highest qualification in nursing, years in
public health nursing and prior case management training. Each of these will be
measured and included in the demographic status section of the study.
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3.1.3.2 Educational Factors
The second category of factors that can influence the effectiveness of CPE
programs is educational factors, including aspects of the educational or training
program such as needs assessment, instructor experience, effective strategies,
program design and learning materials. Several studies have identified factors which
contribute to heightened program effectiveness. Robertson and her colleagues (2003)
examined 15 (post-1993) research syntheses in which continuing education studies
were reviewed in order to investigate what methods of continuing education are
effective. The authors concluded that using a needs assessment, interactive methods
and use of contextual relevance as a base for program development are all factors
more likely to improve participants’ knowledge, skills, behaviours and patient health
outcomes. Conducting a systematic needs assessment is a crucial initial step to
training design and can substantially influence the overall effectiveness of education
programs (Conti, 1996). A needs assessment needs to include evidence from a range
of sources (Robertson et al., 2003). Positive education outcomes are also associated
with the use of gap-analysis techniques (Davis, Thomson, Oxman, & Haynes, 1995).
In addition, Robertson and colleagues (2003) identified several effective
ways of stimulating behaviour change, for instance by linking learning to clinical
practice through interactive educational strategies using a combination of educational
strategies which are more effective than single educational strategies (Robertson et
al., 2003). The authors also argue that courses that address knowledge and skills will
most likely remain dominant in the market, as they fill an important role in
performance improvement by paying explicit attention to transfer of education, such
as holding CPE for the entire staff group and adjusting content to fit learners’ needs
(Robertson et al., 2003). According to Cervero’s argument, to be truly effective in
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CPE it is necessary to include a model of learning at the heart of the education
practice. Cervero advocates that CPE providers should use a critical model of the
learner that integrates the development of two forms of knowledge, both
technological and practical. Both forms are necessary to incorporate scientific
principles into cases, examples, and real-life experiences (Cervero, 1988).
Transformative learning offers a means by which CPE providers can integrate
learning and context within educational activities. Transformative learning regards
learning as a critically reflective process and supports the goal of adult learning to
help adult learners become more critically reflective, participate more fully and
freely in rational discourse and action, and advance developmental perspectives.
Mezirow (2000) points out that transformative learning should be the cardinal goal of
adult education. Adults learn within this framework by adding to or transforming
perspectives that are more inclusive, discriminating, permeable and integrative of
experience (Mezirow, 2000, p. 224-225). Mezirow’s transformative learning theory
supports the key role of reflection and action in learning.
According to Mezirow (2000), a significant personal transformation involves
subjective reframing, that is, transforming one’s own frame of reference. This often
occurs in response to a disorienting dilemma through a three-part process: critical
reflection on one’s assumptions, discourse to validate the critically reflective insight,
and action (Melnyk et al., 2004; Mezirow, 2000). Mezirow (2000) states that not all
reflection leads to transformative learning. He differentiates among three types of
reflection on experience, only one of which, premise reflection, can lead to
transformative learning. Premise reflection, or critical reflection on assumptions, can
be undertaken on assumptions individuals hold regarding the self, the cultural system
in which they live, their workplace, or feelings and dispositions (Mezirow, 2000). In
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premise reflection, the assumptions, belief, or value underlying the problem are
questioned. This process can lead to transformative learning (Cranton, 2002).
Critical reflection can lead to changes in one’s perspective on practice or it
can serve to confirm current practice. However, not all adult education involves
reflective learning. As Criticos (1993) observed, what is valuable is not the
experience itself but the intellectual growth that follows the process of reflection on
experience. Effective learning does not follow from a positive experience, but from
effective reflection. Critical reflection and reflective discourse are used to facilitate
transformative learning. Without these processes, it is unlikely that the act of
learning will be truly transformative (Feinstein, 2004).
Within the transformative learning theory, some teaching strategies have been
identified to achieve transformation. Cranton (2002) identifies the following seven
points as a guide to helping establish a learning environment to promote
transformation.
1. Creating an activating event: Encourage students to seek out controversial or
unusual ways of understanding a topic.
2. Articulating assumptions, that is, recognising underlying assumptions that have
been uncritically assimilated and are largely unconscious.
3. Critical self-reflection, that is, questioning and examining assumptions in terms
of where they came from, the consequences of holding them, and why they are
important.
4. Being open to alternative viewpoints.
5. Engaging in discourse, where evidence is weighed, arguments assessed,
alternative perspectives explored, and knowledge constructed by consensus.
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6. Revising assumptions and perspectives to make them more open and better
justified.
7. Acting on revisions, behaving, talking, and thinking in a way that is congruent
with transformed assumptions or perspectives.
Among these principles, two important components are likely to be addressed:
critical reflection to revise assumptions and perspectives; and action in the revised
assumptions and perspectives. Mezirow’s transformative learning theory emphasises
the key role of reflection and action in learning and transformation. Hence, critical
reflection and action, which can be seen as the core components and principles of
transformative learning, were incorporated into the present education program.
Previous nursing education programs have attempted to use transformative
learning principles through small group methods. Individuals can have questioning
discussions wherein information can be shared openly and consensual understanding
can be achieved (Mezirow, 1991, p. 307). For example, Eisen (2001) applied
transformative learning theory through peer learning partnerships, which are
reciprocal helping relationships between individuals who share a common or closely
related learning objective. Use of peer group approaches was recommended to
promote joint reflection and reciprocal learning between professionals for
professional development and transformation (Eisen, 2001). In terms of a concrete
means of achieving transformative learning during the education process, some
learning methods are also described in the literature. These include discussion,
experiential learning projects, critical incidents, role plays, critical debates, writing
letters or memos, setting up action plans or writing down two or three concrete things
the participants will do, plans with goals, strategies for achieving those goals, and
mechanisms for obtaining feedback from others (Cranton, 2002).
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To summarise these descriptions, transformative learning regards adult
learning as a reflective process to change individual’s assumptions and perspectives.
By acting on the revisions, assumptions and perspectives, transformation can be
achieved. One method that emerges from this is through peer groups, which has been
identified as a successful learning method to achieve transformation. A peer group
promotes sharing of partners’ experiences through reflection and action in the
context of actual practice (Eisen, 2001). Discussions and writing down actions plans,
which include the concrete things participants can do, are identified as concrete
strategies to achieve transformation learning. Hence, guided peer group discussions
and action plans could be used to achieve transfer performance and were integrated
into the current educational program.
Based on the results of literature review a series of steps can be identified and
implemented in order to improve continuing education outcomes. These features are
the use of a comprehensive needs assessment to identify the appropriate learning
needs and the knowledge gap, the use of multiple learning strategies combining
interactive methods, the implementation of programs focusing on transferring
learned knowledge and skills, the use of critical reflection and action plans drawn
from transformative learning strategies through guided peer group discussion to
integrate technological and practical knowledge, and collaboration between nursing
academia and the workplace. Thus existing evidence about the role of training
characteristics can be used to inform program development and delivery in the
current study.
3.1.3.3 Organisational Factors
The last category of factors that influence CPE refers to the context in which
education or training is implemented, also known as organisational or situational
76
characteristics. These include organisational support, resources, policies and standard
practice. These organisational factors are directly related to transfer performance
(Tannenbaum, Coannon-Bowers, Salas, & Mathjeu, 1993). According to research by
Stolee and colleagues (2005), organisational support is the most important factor
influencing the effectiveness of continuing education. Hence, obtaining
organisational support can be considered a crucial factor in order to improve the
effectiveness of CPE.
Some potential organisational barriers to the success of CPE have also been
identified in the literature. Nolan and colleagues (1995) identified a shortage of time,
money, availability of sufficient CPE opportunities, poor information, staff shortages
inhibiting release from the workplace, workload pressures and lack of
encouragement from managers as factors that inhibit the uptake of continuing
education. Focus groups conducted by Stolee and colleagues (2005) also found that
resources were the factor affecting continuing education effectiveness, such as
funding, workload, physical space, and equipment. In terms of the current study,
clearly these factors need addressing to ensure maximum uptake of continuing
professional education opportunities by all qualified nursing staff. Means of
addressing such issues could include consideration in terms of working times, full
information about CPE, and no charge for attendance.
3.2 CASE MANAGEMENT CONTINUING PROFESSIONAL
EDUCATION
Education is vital to the success of any health care professional. Continuing
professional education provides an important means of acquiring or maintaining case
management abilities (Kulbok & Utz, 1999). Continuing nursing education programs
77
usually constitute a single case management course or a series of courses about case
management embedded within another program (Powell, 2000). They often describe
the basic strategies and issues necessary to function in a case management role.
Options for educational programs include undergraduate and postgraduate courses,
staff orientation, on-line learning programs, and collaborative programs. They are
often developed in the USA and the UK (Jackson, 2006; Kulbok & Utz, 1999; Nolan
et al., 1998; Tholcken et al., 2004). All of these continuing professional education
programs can be categorised either as award or non-award programs.
3.2.1 Award CM Educational Programs
Award programs refer to those courses providing qualification programs in
colleges or universities. Case management education is diverse and includes some
formal undergraduate and graduate course content (Falter et al., 1999). As early as
1986, the American Association of the College of Nursing identified case
management skills as essential skills for baccalaureate-prepared nurses. In 1991 the
American Nurses Association (ANA) recommended using nurse case management to
better manage the care of clients with extensive needs. Hence, identification of role
complexity and application contexts resulted in the inclusion of case management in
undergraduate and graduate curricula in the early 1990s (Haw, 1996).
Over the past few years the number of case management courses offered in
nursing programs and in various stages of preparation has increased. In 1996, Haw’s
national survey in the USA revealed that 108 graduate and 98 undergraduate nursing
programs included case management content and clinical experiences, and 95% of
undergraduate programs provided some case management content (Haw, 1996). In
2002, Scheyett’s survey of 100 large state universities found that the highest overall
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number of case management courses, as well as case management-specific courses
focusing exclusively on case management content, were in the nursing field
(Scheyett, 2002). A range of college courses and university programs have been
developed for case management, including courses available at the University of
Melbourne (Australia) and at San Francisco State University, the University of
California, the University of North Colorado, the University of Mississippi, and the
University of Arizona in the USA (Powell, 2000).
Although case management theory has been introduced into some
undergraduate and graduate curricula, those presently employed in the field of health
care have probably not been introduced to these concepts through formal education.
However, establishing more formal academic case management education programs
(such as undergraduate or postgraduate education) would take time and may not meet
the immediate needs for current case managers. To meet this need, in terms of
professional case management development, other types of educational programs are
often used, such as certificated case management programs or short courses with or
without assessment. These are usually referred to as non-award educational programs.
3.2.2 Non-award CM Educational Programs
Non-award educational programs refer to less formal programs, with or
without assessment. There are several non-award CM educational programs available
to prepare nurses to act as case managers. The courses are designed to meet the
immediate needs of the workplace, because staff are required to apply the knowledge
to their practice immediately. Such programs can be offered either by internal or
external providers. A variety of program delivery providers, including institution-
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based orientation programs, seminars, online courses, and collaborative education
programs are identified in the literature.
In order to meet immediate workplace needs, many institutions or hospitals
offer case management orientation programs for their staff. Orientation programs are
usually done within practice settings and often offered by on-site senior staff at the
institution and provide introductory sessions relating to procedures and
responsibilities about their case management programs for new staff (Cohen & Cesta,
2005a; Powell, 2000). Institution-based orientation programs focus on how case
management will be implemented in their organisation, rather than core knowledge
and needed skills. The organisation benefits by ensuring that everyone in the
organisation knows what a case manager does and how the case manager fits into
workers’ daily routines. However, for an innovative service delivery model such as
case management in Taiwan, orientation training may lack a systematic course
framework to prepare nurses to act in new case manager roles. That is, this type of
program may just offer instructions regarding their roles and functions, and not
include case management-related concepts.
In order to offer systematic training for professionals, some training programs
have been developed for new case managers. These programs are usually offered by
professional institutions or outside experts in the field. For example, Cohen and
Cesta (2005a) introduced a three-day seminar designed to educate and train potential
case managers. Day one included the concepts of leadership and management; Day
Two provided an overview and definition of case management; and Day three
reviewed the roles and functions of the case managers. This kind of program is
comprehensive for preparing a new case manager but it may be difficult for all
working nurses to attend such a three day seminar due to practical difficulties of
80
nurses needing to continue to provide services. The more preparation and education
provided to all members of the organisation, the greater are the chances for success
(Cohen & Cesta, 2005a). Attending a three-day seminar may not be possible for all
public health nurses because of their ongoing work responsibilities. Hence, finding
ways for all nurses to be able to attend case management education may increase the
chances for success of case management work.
Online programs are another type of case management education available,
and refer to web-based training (sometimes called electronic learning) which is
anywhere, anytime instruction delivered over the internet. Nurses can thus access the
course when they have time. Some online case management programs include the
courses run by the University of Oklahoma, Canyon College, Johnson County
Community College, and the University of Southern Indiana. These programs vary
widely in length, numbers of classroom versus clinical hours of teaching, and credit
earned. There can also be a wide variation in the nature and quality of education
units. These programs may have potential advantages in terms of access,
convenience and flexibility (Preheim, 2005), however best-case learning requires
initiative, interest, interaction and involvement. Limitations of on-line programs
include complex technical support, uncontrolled contact hours, variable course
quality, limited interaction, lack of immediate feedback and explanation from
instructors. All of these issues may impact on learning outcomes (Preheim, 2005).
Collaborative programs provided at the workplace have appeared as a new
trend in case management education for nurses (Mott, 2000), with an increasing
number of collaborative arrangements between universities and workplaces. Most
commonly, professional associations and formal educational institutions (college,
universities, and professional schools) collaborate to provide continuing education
81
for case management in the field (Mott, 2000). Many authors agree with this
argument and suggest that collaboration between practice settings and academia is
essential for nurses to assume their new roles (Gebbie & Hwang, 2000; James, 2004;
Nalle, Brown, & Herrin, 2001; Palmer, Cox, Callister, Johnsen, & Matsumura, 2005).
Recent reports suggest that collaborative experiences tend to be successful for all
involved (Chang et al., 2002; James, 2004; McWhirter, Courage, & Yearwood.Dixon,
2003; Nalle et al., 2001).
An example of this is the research by Nalle and colleagues (2001), who
developed a collaborative model between nursing academia and nursing practice
focusing on continuing education. They found many benefits of this approach,
including networking, shared knowledge and expertise, and cost savings (Nalle et al.,
2001). The study by Palmer and colleagues also used collaboration to improve the
relationship between academia and service (Palmer et al., 2005). In terms of specific
CM training, Papenhausen and colleagues (1999) conducted a collaborative
implementation of a service-academic partnership that was designed to provide case
management education to employees of medical centres. They used an educational
program provided at the workplace, which was specially designed to meet the needs
of the full-time employed nurses that were participating. The courses were offered at
the medical centre facility, at convenient times, by the university faculty. The usual
class size for these programs tended to be small (approximately 10 to 20 students for
lecture courses) (Papenhausen et al., 1999).
In summary, an analysis of different case management education programs
has revealed that collaborative case management education programs incorporating
both educational and clinical settings are a successful strategy for preparing public
health nurses for case management work in Taiwan. This strategy is easy to access
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and can be systemic, structured, and produce a quality product. It also takes a
relatively short time to develop, as compared with other programs, and can offer an
immediate means of addressing the lack of case management training for PHNs in
Taiwan. By no means is this a perfect solution, as weaknesses such as lack of time to
attend and lack of motivation by PHNs may still need to be overcome.
Until now, few formal education programs have been available for nurses in
Taiwan to provide education or training in the field of case management. Hence,
systematic collaborative continuing professional education (CPE) between nursing
academia and nursing practice can be seen as a means of preparing staff nurses for
case management work, allowing them to meet the new technology and
multidisciplinary skills required for health care services with the benefits of
networking, shared knowledge and expertise, and cost savings.
3.3 REVIEW OF CMCPE PROGRAMS
There are many case management continuing professional education
(CMCPE) programs available for nurses or case managers, as described in curricula
materials, journal articles, and textbooks (Cohen & Cesta, 2005a; Dickerson &
Mansfield, 2003; Fletcher & Coffman, 1999; Powell, 2000; Rothman & Sager, 1998;
Tholcken et al., 2004). For the purpose of the proposed research, a review of the
literature from social service, health care, and nursing fields from 1990 was
undertaken. “Case management or care management” and “continuing education or
professional development” and “nurses or case managers” and “evaluation or
effectiveness or outcomes” were used as key words for the search. Databases
included CINAHL, Pre-CINAHL, ERIC, MEDLINE, Primary Search, Professional
Development Collection, PsycINFO, and Academic Search Elite. A total of 19
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program evaluation studies fitted the criteria for the review and are discussed in the
following section. Table 3.2 provides a summary of these studies, including the
location of the study, the sample and evaluation methods, the content and program
design, the effectiveness of the training, and the measurement tools used. Given their
relevance to the aims of the current project, program design, evaluation methods and
outcome measures will be discussed in detail. Finally, the limitations of the existing
research will be identified.
3.3.1 Program Design
Program design is a decision-making process that allows educators to identify
the most important elements of the learning process and to make decisions about
what will be the most effective way to plan and implement learning activities
(O'Loughlin, 2002). In terms of program design, a theoretical framework offers
systematic information about the factors influencing the program, how learning takes
place and transferred to practice, and what outcomes are achieved and evaluated.
Unfortunately, most of the CMCPE programs available do not describe the program
framework they used. The selected CMCPE programs can be roughly divided into
two main domains according to their aim, either seeking to provide new knowledge
or strategies to case managers, or aiming to teach specific case management delivery
models or approaches.
First to be examined are studies which sought to update the knowledge of
nurses or case managers in case management practice. Of the 19 selected programs,
six programs delivered both required knowledge and skills for case managers to
function in their roles effectively. All of these programs were designed to prepare
nurses for their responsibilities and help them provide appropriate case management
84
services. These are presented in Table 3.1 with more details of these programs.
Matrone’s (1990) study involved the implementation of a staff development program
designed to improve nurses’ case management competencies. Connor (1992)
provided a service which sought to deliver essential knowledge and skills for nurse
case managers. Smith and Wolf (1997) offered an orientation program focusing on
four competence domains. Smith and colleagues (1998) used a program designed to
prepare nursing staff to competently function in their case manager roles. McClaran
and colleagues’ (1999) course focused on four components on case management
aimed at multiple professions and presented at a team meeting. Finally, Dickerson
and Mansfield (2003) offered an orientation program directed at enhancing the skill
level of new case manager employees. These programs all had similar goals, namely
to prepare nurses (or related professionals) for their role as case managers, and to
maximise participants’ knowledge and skills of case management so that they can
function successfully in the case manager role.
However, the majority of the remaining programs focused on delivering very
specific knowledge and skills needed for case managers working with specific
populations, such as elder abuse (Vinton, 1993), HIV clients (Linsk et al., 2002;
Shelton et al., 2006) and work-related upper extremity disorder (Shaw et al., 2001).
The various knowledge and skills delivered included therapy (such as cognitive
therapy) (Hafner et al., 1996), side-effects of medication (Morrison et al., 2000),
violence prevention (Weisman & Lamberti, 2002), and specific skills and strategies
(such as assessment skills and instrument use) (Donoghue et al., 2004; Landi et al.,
1996).
The other category of programs is those that delivered information about a
specific case management model. Four of the reviewed studies focused on a single
85
case management model or case management approach for specific populations,
including a broker model in palliative care, a strength model for psychiatric patients,
a new nursing delivery model for frail older people, services for a work-related upper
extremity disorder, and diarrhoea case management (Howell et al., 2004; Shaw,
Feuerstein, Lincoin, & Miller, 2001; Sheaffer, Phillips, Donlevy, & Pietruch, 1998;
Stanard, 1999). These programs were thus designed to deliver a new case
management model specifically tailored to their organisations in order to prepare
staff to work under their health care system.
It is difficult to review these programs as a whole, as each presented varied
program content based on their different organisation’s concerns and goals. For
instance, one program may focus on training staff for the changing context of case
management practice, while another may deliver general case management
knowledge and skills, and yet another may instruct their new staff in a specific case
management model. The program content and level of CMCPE depends on
organisational needs and the academic background of nursing staff. For example,
when training staff in the delivery of an innovative service delivery mode, the most
appropriate program would incorporate an orientation and introduction to the model.
In contrast, for those organisations which are in the initial development stage or have
not established a specific case management model, a course encompassing essential
knowledge, skills and related concepts in case management practice may be required
to meet workplace needs. This is especially true when nursing staff need to apply
skills to their new changing practice without delay. This is currently the case for
Taiwanese public health nurses.
As revealed earlier through the literature review, a needs assessment is one
means of ensuring that the program content of a case management education
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program meets the needs of nurse case managers, and the delivery methods fit their
learning preferences. Needs assessments refer to the process of identifying the
learning needs of the target populations and how this will contribute to an overall
strategy of training and education (Furze & Pearcey, 1999). It can confirm the
educational needs of the population. Evidence suggests that programs based on a
needs assessment are more likely to improve knowledge, skills, behaviours and
patient health outcomes (Robertson et al., 2003). However, among these 19 programs
assessed here, only two—Dickerson (2003) and Howell and colleagues (2004)—
described a learning needs assessment. They used information from the organisation
and a survey of the learners, but none of these studies mentioned the participants’
learning preferences. Neither of the two studies explored public health nurses’
educational needs in case management using focus group discussions as a data
collection method.
The reviewed programs varied in the nature of the providers and the length of
the educational programs, but no program was identified in which the design was
based on a theoretical framework. Such a framework can allow the program designer
to carefully consider potential factors influencing effectiveness of the continuing
education program, and hence guide program design and delivery. Furthermore, no
program had specifically attempted to undertake collaboration between nursing
academics and clinical nurses. Such deficits in these programs may have affected the
ability of participants to link their learning to clinical practice, and in turn influenced
the effectiveness of the programs. Variations in program characteristics emerge
mainly from the different goals and foci of these programs. The time period of the
program varied according to whether the course focused on specific skills or overall
competences, and ranged in length from a single three-hour session to a four week
87
orientation program. According to Fineman (1996), development of the case
management course should reflect all elements and characteristics of the case
management process. Several reviewed programs had systematic courses ranging
from 16 hours to one week to prepare new case managers. (Connors, 1992; Howell et
al., 2004; Matrone, 1990; Shaw et al., 2001; Smith & Wolf, 1997; Stanard, 1999).
Education of new case managers requires several days to weeks depending on
the specific purposes of the organisations and available time offered for nursing staff
(Cohen & Cesta, 2005b). The length of the continuing education program will
depend on the practical considerations relating to the time that workers can take from
their units to attend the educational program. For example, McClaran and colleagues
(1999) taught case management in three-hour team meetings attended by
multidisciplinary groups because the different professionals were not able spare more
time. In contrast, Landi and colleagues (1996) conducted a four-week course
preparing individuals for the case manager role. Hence, for the context in Taiwan, 16
hours was considered the minimum length to prepare nurses for the case manager
role but available time offered by the organisations also needs to be considered to
ensure that everyone can attend (Cohen & Cesta, 2005a).
Despite these differences in the length of these educational programs, the
educational methods used in the programs were very similar in that they tended to
deliver programs through a combination of several learning strategies. For example,
the program by Sheaffer and her colleagues (1998) was presented over four hours,
and included an oral presentation with specific examples to enhance staff nurses’
understanding and the acceptance of a new case management model. Dickerson and
Mansfield’s program comprised seminars, written projects and group discussion or
activities (Dickerson & Mansfield, 2003). Similarly, McClaran mixed lectures
88
addressing each main concept with a discussion of actual cases, and Howell and
colleagues used didactic techniques, small group discussions and case-based learning
(Howell et al., 2004; McClaran, Lam, Franco, & Snell, 1999). However, none of the
programs described here specifically addressed the learning strategies identified by
learning and education theories to ensure the transfer between learning and clinical
practice. In addition, the programs failed to consider their participants’ learning
preferences, which may have affected their motivation. These weaknesses may have
influenced the ability of participants to link their learning to their clinical practice
and hence affected the participants’ motivation for attending continuing educational
programs.
Didactic lectures still remain the main strategy applied in these case
management education programs because didactic methods are beneficial for
delivering new knowledge and concepts. For the most part concepts of case
management are relatively new to most nurses, so didactic methods are important for
case management education (Cohen & Cesta, 2005a). In addition, many reviewed
programs used group discussions to link learning content closely to the learners’
practical work and share experience between the participants. This is consistent with
the evidence described earlier, which suggests that the most effective techniques use
interactive methods, contextual relevance and combinations of multiple learning
strategies. Hence, both didactic lectures and direct linking of learned content to
clinical practice need to be carefully considered when designing this educational
program.
In summary, existing CMCPE programs have focused on allowing case
managers to acquire specialised knowledge, skills, and models. According to the
evidence, the length of a program needs to be at least 16 hours and participating
89
organisations need to allow time for all nurses to attend. It is clear that a combination
of learning strategies, incorporating interactive lectures and small group discussions,
are often used in case management educational programs and are associated with
positive learning outcomes. However, few programs have addressed their
participants’ educational needs in case management and none have used a theoretical
framework to guide their program design to ensure the program’s effectiveness. In
addition, few of these reviewed programs were designed according to a needs
assessment (in order to fit participants’ learning preferences) or were based on a
theoretical framework that carefully considered influencing factors and addressed the
transfer of learning to practice. On the basis of this review, it is concluded that there
is a need to develop a case management continuing education program based on a
needs assessment in order to meet nurses’ immediate needs in case management
practice in the context of their work environment. This educational program needs to
be guided by a theoretical framework and a learning theory to enhance effectiveness
and permit the transfer of learning to practice. These issues will be addressed in the
current study in order to best design an evidence-based educational program which
will potentially improve learning outcomes.
3.3.2 Research Design for Evaluation
This section reviewed and critiqued the evaluations undertaken in the selected
programs, including factors such as the participants, research design, and data
collection methods. The majority of the reviewed programs were designed for
hospital-based nursing staff and used small convenience samples (between 5 to 150)
although a single study had a larger sample size of 722 (Linsk et al., 2002). None of
these programs were offered to public health nurses, and none were conducted in
Taiwan.
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Most studies evaluated program effectiveness using only a single treatment
group, and included no comparison or control group. Aylward and colleagues argued
that the methodology used to evaluate an educational intervention has to be
scientifically rigorous to demonstrate the evidence of the effectiveness of CPE
(Aylward, Stolee, Keat, & Johncox, 2003). However, the methodological designs of
these evaluation studies were relatively limited. Fifteen of the 19 studies used single
group pre- and post-test designs. The remaining four studies adopted a quasi-
experimental design, but did not randomise the allocation of participants to
experimental and comparison groups (Connor, 1992; Flores, Robles & Burkhalter,
2002; Matrone, 1990; Morrison et al., 2000). None of the reviewed studies
implemented the most experimentally rigorous approach, a randomised controlled
design.
Another limitation in most of the evaluation studies was the use of a single
data collection method. The three notable exceptions to this (Donoghue et al., 2004;
Howell et al., 2004; Morrison et al., 2000) used a mixed method design, but had
relatively few participants and lacked reliable and validated measures. The most
common technique adopted across all of the studies was use of a questionnaire,
although one study conducted focus group discussions (Dickerson & Mansfield,
2003). A single program by Donoghue (2004) used both quantitative and qualitative
data collection methods, using questionnaires assessing knowledge, attitudes,
practice and satisfaction to collect quantitative data, focus groups to gather feedback
(Donoghue et al., 2004).
Thus these evaluations of CPE programs in case management show serious
methodological weaknesses. The studies tended to have small samples, few studies
used an experimental research design with two groups, and only one used qualitative
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as well as quantitative data to provide an in-depth exploration of their effectiveness.
In terms of the context of the current study, none of these available programs were
designed for PHNs or for the Taiwanese health care system. Future case management
educational interventions must use more scientifically rigorous methodology to
demonstrate their effectiveness. Hence, the current study will seek to develop and
evaluate the effectiveness of a case management continuing education program using
best-case practices (an experimental design, random allocation of participants) with a
novel set of participants (PHNs) in a new context (Taiwan) in order to contribute to
the current body of evidence about the effectiveness of CMCPE programs.
3.3.3 Outcome Measures
The selected studies revealed the recent increase in authors seeking to
determine the impact of continuing education in changing participants’ knowledge,
skills, and practice performance. These three key outcome variables are discussed in
detail below in terms of the 19 selected studies.
3.3.3.1 Knowledge
Of the 19 reviewed studies, six used knowledge as a program effect indicator.
All of these assessments revealed significant improvements in knowledge level after
the program (Donoghue et al., 2004; Howell et al., 2004; Linsk et al., 2002; Matrone,
1990; Sheaffer et al., 1998; Vinton, 1993). Knowledge level has always been a key
concern for nurse educators or institutions because knowledge is seen as the
foundation of clinical practice. This view is supported by the fact that many
researchers use CPE as a strategy aimed at improving CM practice and providing
their professionals with knowledge about CM (Donoghue et al., 2004; Howell et al.,
2004; Linsk et al., 2002; Matrone, 1990; Sheaffer et al., 1998; Vinton, 1993).
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Most of the knowledge measurement tools implemented in these studies were
consistent with the course content in those education programs (Donoghue et al.,
2004; Howell et al., 2004; Linsk et al., 2002; Matrone, 1990). The most popular
measurement tool used was an examination, testing the participants’ knowledge
using multiple-choice format questions. For example, Matrone’s research involved
the development of an instrument for measuring nurse competency, which included
36 multiple-choice questions and 24 true or false questions. Vinton (1993) developed
13 knowledge-based questions based on the course content of his program. Linsk and
colleagues’ (2002) knowledge test had 20 questions and Howell and colleagues
(2004) designed 14 multiple-choice questions attempting to measure knowledge.
As used in these studies, multiple-choice questions can be an efficient and
valid method of measuring general professional knowledge. They constitute a simple,
standard test with relatively low grading time (Wood, 1998). They also allow single
format questions with standard validity (DeeSantis & McKean, 2003). Some authors
argue that multiple-choice questions do not allow for testing of higher level cognitive
abilities, as can open-ended questions. However, other authors argue that, such is the
usefulness of multiple-choice questions, that open-ended questions should be used
solely to test aspects that cannot be tested with multiple-choice questions (Schuwirth
& Van Der Vleuten, 2004). Open-ended questions generally lead to lower
reliabilities than multiple-choice questions (Schuwirth & Van Der Vleuten, 2004). It
is also important to remember that multiple-choice questions are no less valid than
open-ended questions. Many institutions or associations use multiple-choice
questions for case manager qualification/certification examinations, such as the
Commission for Case Manager Certification and the Case Management Society of
American (Siefker, Garrett, & Genderen, 1998). Hence, a multiple-choice question
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format can provide efficient and objective evidence for the learning outcomes of a
program.
3.3.3.2 Skills
Several studies have examined the effect of CMCPE programs on
participants’ related skills, however few conclusions can be drawn due to the lack of
comparison groups included in these studies, and weaknesses in the measures used.
Five investigators determined the effect of CMCPE programs on participants’ skills,
including studies by Connors (1992), Landi and colleagues (1996), Smith and
colleagues (1998), Morrison (2000), and Donoghue and colleagues (2004). Two of
these studies delivered an education program aiming to change nurses’ skills in terms
of the case management process. The nurses reported higher confidence and better
perceived preparation for performance of skills, but no difference in reported
frequency of using the skills (Connors, 1992; Smith et al., 1998). Three other studies
focused on acquisition or improvement of specific skills, such as assessment,
decision-making skills and psychological intervention skills (Donoghue et al., 2004;
Landi et al., 1996; Morrison, 2000). In all of these studies, participants demonstrated
better performance of the target skill/s after the program had been completed.
However, the evaluative methods used in these studies may not be able to offer
strong evidence demonstrating the effectiveness of the programs in terms of changes
in skills.
These assessments used a range of tools, including perceived preparation for
specific skills (Connors, 1992), performance confidence level (Smith et al., 1998),
and reported frequency of using particular skills (Connors, 1992; Donoghue et al.,
2004). Although there were positive outcomes in terms of perceived preparation and
confidence in case management skills, these studies failed to report the psychometric
94
data associated with their measurement tools. In addition, these studies found no
significant differences in the frequency of using case management skills before and
after the program. Hence there is a need to expand current knowledge with regard to
the ability of CCMCPE to changing the frequency of using case management skills,
particularly using a comparison group and valid and reliable measurement techniques.
3.3.3.3 Practice
Performance is a broad concept that relates to changes in nurses’ behaviours,
practice, or activities, rather than perceived outcomes or beliefs. According to
Ferguson (1994), performance can reflect the real value of education in terms of
change in practice by the learner. Recently more research has been undertaken into
case management education focusing on behaviour change as an indicator. Again,
these evaluative studies are limited because of weaknesses in their research methods.
Hence, no existing study can reliably demonstrate the effectiveness of a continuing
education program in changing nurses’ case management practice using a
randomised controlled design.
Among the selected studies, five measured changes in participant practice.
Smith and colleagues (1998) and Flores and colleagues (2002) used observers to
determine the effect of their training programs on their participants’ performance.
Dickerson and Mansfield (2003) used group discussions to investigate stated
performance. Donoghue and colleagues (2004) and Howell (2004) combined both
qualitative and quantitative methods to evaluate the impact of their programs on
nurses’ practice. All of these studies concluded improved performance or nursing
practice after completion of the CPE program. However, these studies used small
sample sizes ranging from 32 to 132 and the measurement tools used to assess
changes in participant behaviour have several limitations.
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For example, Flores and colleagues (2002) used 14 trained observers to rate
their participants’ performance according to five indicators. This observation method,
also used by Smith and colleagues, is well known for being associated with the
Hawthorne effect. The Flores study also failed to report the level of reliability
estimated between the different observers’ records. The study by Dickerson (2003)
used program feedback sheets handed out to both case manager supervisors and
participants as a means of assessing the education program. Thus, across the board,
there was often a lack of standard measuring procedures and studies frequently failed
to report reliability and validity of their measurements. As criticisms of these three
studies reveal, using a mixed methods approach to evaluation should offer more
comprehensive means of assessing the effectiveness of educational programs.
The use of mixed methods has increased in recent years as it has been found
that a combination of methods can achieve a more complete picture of the success of
an education program. Questionnaires and structured group discussions are among
accepted methods. Hounsell (2003) reported that the questionnaire is extremely
popular for this use, in concert with student panels and focus groups, which offer less
formal and relatively open-ended ways for participants to constructively exchange
and pool thoughts and reactions. Many other educational studies have combined
questionnaires and focus groups to evaluate their programs (Bowles, Mackintosh, &
Torn, 2001; Chivers, 2006; Donoghue et al., 2004), with these authors arguing that
using a mixed method contributed to a comprehensive evaluation of their educational
program, in terms of both educational processes and outcomes.
Within the reviewed studies, Donoghue and colleagues (2004) and Howell
and colleagues (2004) used both quantitative and qualitative methods to explore their
participants’ learning outcomes and stated changes in practice. They used
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quantitative methods (questionnaires) and qualitative data (focus groups or written
feedback) to evaluate the educational programs. However, the two studies failed to
report the psychometric data associated with their quantitative measurements, used
small sample sizes with 32 and 55 participants and had no comparison group. These
limitations restrict the conclusiveness of the results.
Interestingly, three of the selected studies examined the impact of the
educational program on patient outcomes (Hafner, 1996; Stanard, 1999; Morrison,
2000). However, these studies do not offer strong evidence for changes in patient
outcomes because of small sample sizes and limited research designs (e.g.,
uncontrolled external factors). Hafner and colleagues (1996) did not include a
comparison group in their study, which restricts interpretations of their findings. In
addition, the participants in the experimental and comparison groups of the studies
led by Stanard and Morrison (1999) had different baselines in terms of age, diagnosis
and gender, and the two studies failed to control for these differences. The samples in
the two groups of these two studies were small and also came from two different
community settings and hospitals, and the studies failed to control for the effect of
organisational factors (e.g., staff numbers and staff workloads). It is thus very
difficult to draw conclusions regarding the cause-effect relationships of patient
outcomes for these two studies, given the lack of control over these external factors.
As Jordan (2000) points out, the practical, ethical and budgetary difficulties, such as
an increased risk of the Hawthorne effect, are potential pitfalls when measuring
changes in terms of patient outcomes.
The studies reviewed here are greatly concerned about the learning level of
evaluation. All of these studies assessed nurses’ self-perception of program outcomes
as part of their evaluation data, and indeed, often it constituted the total of the
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evaluation data. There were no assessments conducted in these studies of the
multiple levels of evaluation, combining levels I to III. Fourteen of the reviewed
studies focused on a single level of evaluation. Only five studies evaluated two levels
of outcomes (Hafner, 1996; Morrison, 2000; Dickerson, 2003; Donoghue, 2004;
Shelton, 2006). These restricted evaluation methods suggest that future studies
should measure multiple levels of outcomes where possible.
3.4 LIMITATIONS AND GAPS IN EXISTING RESEARCH
Several limitations of existing research have been identified during the
literature review. In terms of educational program design, learning strategies with
interactive lectures and small group discussions, have been used and are associated
with positive outcomes. However, few case management education programs were
built from a needs assessment and theoretical basis when developing their
educational interventions. In addition, existing evaluation studies have contained
methodological weaknesses because few of these studies were conducted using an
experimental research design. Sixteen of the 19 studies used single group pre- and
post-test designs and the remaining studies used only a quasi-experimental research
design. Most of these studies also used a single method to collect data, and although
three notable studies used mixed methods (Donoghue et al., 2004; Howell et al.,
2004; Morrison et al., 2000) these studies had relatively few participants and lacked
reliable and valid measurement tools. Overall, sample size ranged widely and was
small. None of the studies used a theoretical framework which integrated influencing
factors, evidence-based learning strategies and multiple levels of outcomes to guide
the program development, delivery and evaluation. Instead, most studies focused on
a single level evaluation, at the reaction, learning, or behaviour level, and none
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measured integrated multiple levels of evaluation. In terms of the focus of the current
study, none of these programs were suitable as a basic case management education
program for public health nurses, and none were designed for public health nurses in
Taiwan. Given the state of current research in this field there is thus a basis for
developing an evidence-based educational program for public health nurses working
as case managers in Taiwan.
3.5 SUMMARY
This chapter discussed the evaluation of CPE programs, describing four
possible levels of evaluation. The effectiveness of CPE programs can be
demonstrated through changes in nurses’ knowledge, skills and practice. Individual,
training and organisational factors may influence the effectiveness of CPE programs.
Collaborative case management continuing professional education (CCMCPE)
programs between nursing academia and nursing practice appears to be an effective
means of preparing nurses for case management practice. Nineteen existing
evaluation studies of CPE programs related to case management were reviewed and
criticised. Interactive lectures and peer group discussions were identified as effective
learning strategies in case management education. To ensure success with a program,
the length of the program needs to be at least 16 hours duration and it is important to
make sure that all nursing staff can attend the course. Limitations of these studies, in
terms of evaluation methods and research design used, were then identified.
Limitations shown by all studies included the lack of a needs assessment (hence an
inability to adapt to participants’ learning preferences), lack of a theoretical
framework in order to consider potential influencing factors, lack of theory-based or
evidence-based learning strategies in the program delivery in order to link learning to
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clinical practice, and the exclusion of tests of multiple levels of outcomes using a
randomised controlled design. All such issues clearly guided the research questions
adopted in the current study, and affected the research design when developing,
implementing and evaluating the effectiveness of this case management continuing
educational program.
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Table 3.1
Summary of selected case management continuing education studies
Title, Author, Year & Country Evaluation Methods Program Design Results Measurement tools
Matrone (1990) in the USA. The effect of a staff development program on nursing case management competency and patient outcomes in the acute care setting.
A quasi-experimental design; convenience 45 nurses in acute care setting
16 hours; in-hospital; competency for a case management role
Significant difference in competency of making nursing diagnoses, communication and managing patient care
Case manager staff development examination tool in acute care setting, self report scale developed by the author; assessments of reliability and validity
Connors (1992) in the USA. Case management: Within and beyond the walls.
A quasi-experimental design; 65 nurses in experimental group and 57 in comparison group
64 contact hours; multiple teaching strategies; essential knowledge and skills for case managers
No difference in frequency of use of skills; difference in the perceived preparation for performance of skills
Competency Behaviours of the Case Managers Inventory (CBCMI) developed by the author
Vinton (1993) in the USA. Educating case managers about elder abuse and neglect.
One group pre-post tests; 142 participants including multiple professionals in the community
Half-day, seven identical sessions; no charge; size ranged from 14 to 25; professor of social work as instructor; elder abuse and neglect prevention
Significantly increased knowledge scores; case managers showed the greatest improvement compared to other occupational groups
Knowledge by questionnaire 13 questions developed by author
Landi et al. (1996) in Italy. A simple program to train case managers in community elderly care.
One group with post test; 14 nurses
Four weeks, 20 days; knowledge of comprehensive assessment instrument; one assoc. professor of Gerontology, two physicians of Geriatrics, a head nurse (PhD Soc.) in presentation and group discussion
More accurate and consistent care planning between nurses
Tested on assessment and decision-making skills using five written cases and two videotapes
Hafner et al. (1996) in Australia. Training case managers in cognitive behaviour therapy.
One group with post test; 4 nurse case managers and 10 patients
1.5 hours for related practical and theoretical issues for 22 meetings, 10 one hour supervision sessions through in-service program; developing basic skills in cognitive-behaviour therapy
Patients’ symptoms improved significantly; case managers began treating patients autonomously
The brief symptom inventory
Smith & Wolf (1997) in the USA. Orientation program for a hospital-based dual case manager and educator role.
One group with post evaluation; 7 nurse case managers/educators in hospital
5 days of didactic and clinical orientation 16 weeks; four competency domains of case manager/educator
Positive in overall satisfaction Overall satisfaction with the program rated from 1 to 5
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Table 3.1(cont’d).
Summary of selected case management education effectiveness studies
Title, Author, Year & Country Evaluation Methods Program Design Results Measurement tools
Smith et al. (1998) in the USA. Evaluation of a case manager in service training program.
One group with post test; multiple evaluation methods; clinical nursing staff in acute care setting
Three days of classroom and one day planning problem solving; patient care coordinator preparation; maximise skills of participants in the hospital-based case manager role; conceptual framework for care coordination
High confidence in case management process but case management skills such as coordination, negotiation, collaboration, effective communication required more attention
Self assessment questionnaire, case manager performance assessment tool, and case manager performance confidence; direct observation method (high cost)
Sheaffer et al. (1998) in the USA. Continuing education as a facilitator of change: Implementing a new nursing delivery model.
One group with pre-post tests; 106 nurses in hospital
4 hour sessions; a new nursing case management delivery model
Differences on the knowledge level and attitudes to new case management model
Level of knowledge; need for change scale; My Role Scale to measure attitudes
McClaran et al (1999) in Canada. Can case management be taught in a multidisciplinary forum?
One group with pre-post tests; 50 multidisciplinary participants in hospitals
3 hours on-site workshop on case management, including 45 minutes lecture in four themes and developing alternative care plans
Significant differences in perceived importance of case management; no differences in evaluation by the different professional teams
Perceived important on visual analogy scales with 100 mm; program and process evaluation with eight factors
Stanard (1999) in the USA. The effect of training in a strengths models of case management on client outcomes in a community mental health centre.
Two non-equivalent groups with pre-and post tests; 29 patients in experimental group; 15 patients in community control group
40 hours strength model of case management
Quality of life improved; no difference in hospital days and hospital rate
Quality of Life Inventory (QOLI); HSCL-90; information sheet
Morrison et al (2000) in Australia. Enhancing case managers’ skills in the assessment and management of antipsychotic medication side-effects.
Two groups with pre-post tests; 22 case managers of multiple professionals; 44 patients (20 comparison and 24 intervention)
Two half-day workshops, including training in assessment and management of narcoleptic side-effects
Reduction in side-effect scores; Qualitative results: patient acquired positive strategies from case managers
Liverpool University Neuroleptic Side-effect Rating Scale
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Table 3.1 (cont’d)
Summary of selected case management education effectiveness studies
Title, Author, Year & Country Evaluation Methods Program Design Results Measurement tools
Shaw et al. (2001) in the USA. Case management services for work-related upper extremity disorder.
One group with post tests; 65 nurse case managers
2 days with 16 hours workshop; didactic presentations, case simulations, and hands on exercises; trainers included psychologist, an ergonomist, a staff nurse; no charge
Moderate to high self-rating of confidence to use case management approach
Self-rating confidence level from 1 to 10; satisfactory scale of 1 to 5
Flores, Robles & Burkhalter (2002) in Guatemala. Distance education with tutoring improves diarrhoea case management in Guatemala.
Two groups with pre-post tests; interview clients; 132 participants (about two-thirds doctors and one-third nurses)
A package of course materials for 10- month period, tutors monitored progress; materials developed by expert working groups; self-evaluation exercises, bibliographies, videotapes, and slides
Case assessed and classified correctly increased by 25% more than in control group; treatment did not improve; counselling improved non-significantly
Using trained observers to five indicators of the quality of care focusing on functions of case management, including assessment, classification, treatment, and counselling
Weisman & Lamberti, 2002 in the USA. Violence prevention and safety training for case management services.
One group with post evaluation; 150 nurses or case managers
10 topics within two 90 mins sessions; Didactic presentation, discussion and sharing experiences, and role-play
Trainee satisfaction with average 8.4
Using 1 to 10 scales (10 being the most satisfied)
Linsk, Mitchell, Despotes, & Cook, 2002 in the USA. Evaluating HIV mental health training: Changes in practice and knowledge for social workers and case managers.
One group pre and post tests; 479 social workers and 243 case managers
Three lectures and small group discussions with problem-based learning
Significant improvement in knowledge
20 questions about the knowledge of HIV
Dickerson & Mansfield (2003) in the USA. Education for effective case management practice.
One group final evaluation with qualitative data through group discussions; 115 new case manager staff
Half-day interactive educational session; orientation program for new employees to enhance skill level of existing case managers; focus on the process of planning and implementing activities to meet needs
Positive feedback from learner; improved organisational performance
Program feedback sheets; follow-up discussion 3 months later
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Table 3.1 (cont’d)
Summary of selected case management education effectiveness studies
Title, Author, Year, and Country Evaluation Methods Program Design Results Measurement tools Donoghue et al. (2004) in Australia. Training case managers to deliver focused psychological strategies.
One group with pre-post assessment using quantitative and qualitative measures; 32 case managers, including nurses, social workers, and psychologists
Ten training modules using a cognitive behavioural therapy through monthly workshop with resource materials; cognitive behavioural therapy as a framework
Attitudinal changes; improved knowledge of psychological therapies; changes to stated practice; expressed their competence and confidence to skills learned into practice
Knowledge by 15 true/false questions; skills by rating how often participants used strategies on four-point scale; post qualitative evaluation via focus group guided by stem questions
Howell et al. (2004) in Canada. Enhancing the role of case managers with specialty populations: Development and evaluation of a palliative care education program.
One group pre, post and three months following tests; overall program evaluation via qualitative data; 55 nurses or case managers
21 hours with 7 topic modules based on learning needs assessment survey for 93 case managers; Multiple teaching methods with didactic methods, small group discussions, case-based learning, and group presentations.
Qualitative results: course content and methods, knowledge enhancement, learning from each other, comfort and confidence; Quantitative results: non-significant difference between pre and post tests; differences between pre and three months and post and three months
Knowledge by 12 true/false and 14 multiple-choice questions;
Shelton, Golin, Smith, Eng, & Kaplan (2006) in the USA. Role of the HIV/AIDS case managers: Analysis of a case management adherence training and coordination program in North Carolina.
Focus group interviews and individual interviews; 16 case managers and 21 clients
One day workshop via didactic lecturers, video training materials and practice specific skills; three months client care plan to identify barriers and outcomes
The top four barriers identified; identified role of case manager; barriers to providing services; strategies for promoting adherence
Focus group and individual interviews
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CHAPTER FOUR
THEORETICAL FRAMEWORK OF PROPOSED PROGRAM
4.1 INTRODUCTION
Best-case program design uses a theoretical basis to guide the development,
implementation and evaluation of the educational program and, as far as possible, to
ensure its effectiveness. This study synthesised an integrated framework for the
current program, because there was no single model or theory that was appropriate
for guiding the development, implementation and evaluation of the intended
educational program. The proposed framework is an expanded version of
Donabedian’s (1992, 2003) structure–process–outcome evaluation model. The
current work integrated factors identified in the literature as influencing effectiveness,
and the three levels of outcome evaluation. This chapter will describe the model used
as a foundation for the study and explain related concepts inherent in this proposed
framework. The model used is illustrated in Figure 4.1.
4.2 OVERVIEW OF THE CCMCPE PROGRAM
FRAMEWORK
The framework underlying the present program used structure, process, and
outcome stages to guide program development, implementation and evaluation.
There were three main characteristics that could affect the CCMCPE program
implementation and subsequently influence public health nurses’ (PHNs) outcomes.
These were individual factors, educational factors, and organisational factors
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(Alvarez et al., 2004; Cervero, 1985; Griscti & Jacono, 2006; Holton, 1996; Kruijver
et al., 2000). Traditionally, these characteristics can be seen as the factors influencing
the effectiveness of education programs, and are viewed in this study as potential
factors influencing the outcomes. These factors will also influence the process of the
CCMCPE program and need to be considered in the program’s development stage.
Hence, an integrated needs assessment was conducted to understand these
influencing factors, and focus groups were used to explore the knowledge required
by PHNs, current case management practice, their learning needs and their preferred
learning methods.
Figure 4.1
Theoretical framework of the proposed program
(expanded from Donabedian’s (1992; 2003) structure-process-outcome model)
Outcomes
Individual factors • Age • Work experience • Educational level • Prior training in CM
Educational factors • Needs assessment • Program design • Effective strategies • Facilitator experiences • Instructional material
Organisational factors • Organisational support • Training resources • Continuing
educational policy • Standard practice
Structure Process
CCMCPE • Collaboration • Case management
process • Essential
knowledge, skills and activities
• Evidence-based educational strategies
Learning Outcomes (Level II) • Improved knowledge
about CM • Improved performance
confidence in case management skills
• Improved preparedness level in case manager role activities
Reported Performance Outcomes (Level III) • Improved frequency of
using case management skills
• Improved frequency of using case manager role activities
• Change in CM practice
Reaction (Level I)
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Program development was then grounded on the findings of the needs
assessment and evidence-based educational practice identified from the literature.
The learning process, incorporating essential knowledge, skills and role-related
activities identified from the literature formed the program content. Multiple leaning
strategies drawn from the case management education literature, needs assessment,
and transformative learning strategies, were used in the learning process to enhance
its potential effectiveness.
The assessment of the effectiveness of the education program comprised
three evaluation levels, including reaction, learning and reported performance
evaluation. The outcome variables, Level I to Level III, were measured at the
beginning and end of the education program, including the satisfaction with the
CCMCPE program (Level I), PHNs’ knowledge about case management (Level II),
performance confidence in case management skills (Level II) and the preparedness
level (Level II), and the self-reported frequency of using case management skills and
selected case manager role activities (Level III). Transfer performance, namely
changes in case management practice, was also assessed in this study, but Level IV
evaluation (patient outcomes) were not assessed due to practical difficulties. Control
of external factors in Taiwan was difficult, which prevented the determination of
which results or patient outcomes were directly linked to the implementation of the
educational program.
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4.3 THEORETICAL BASIS OF THE FRAMEWORK
This section describes Donabedian’s structure–process–outcome model of
quality evaluation and discusses the reasons for its central relevance to this study.
Donabedian (1992, 2003) identifies three approaches to assessing quality of
programs, called ‘structure’, ‘process’, and ‘outcomes’. Donabedian’s model
describes a linear relationship between these variables such that structure influences
process and process influences outcomes, when there is a predetermined relationship
among the three components. It is therefore assumed that better structures lead to
better processes and better processes then lead to better outcomes.
Structure, meaning the characteristics of the system, has an important bearing
on how persons in that system behave. For example, a system with better
organisational resources (e.g., facilities, equipment) or more education for human
resources (e.g., nursing staff) may offer better quality care. Therefore, variations in
health system characteristics yield presumptive judgments on the quality. In the same
way, the characteristics of health care processes can provide valid information about
their quality because quality of care can be taken to mean quality of the process of
care (Donabedian, 2003). In addition, in this model the processes are seen to be more
directly related to outcomes than are the structure factors. Outcomes are taken to
mean changes in individuals and populations that can be attributed to health care,
including changes in health status, changes in knowledge, changes in behaviours and
satisfaction of patients (Donabedian, 2003).
Donabedian’s model has been described by Stalzer and colleagues (Salzer,
Nixon, Schut, Karver, & Bickman, 1997) as the most popular and frequently cited
conceptualisation of quality programs. Donabedian’s model has gained widespread
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acceptance over the last 30 years because of its predetermined relationship and
almost intuitive persuasiveness (Donabedian, 2003; Hawkins & Sherwood, 1999;
Yakimo, Kurlowicz, & Murray, 2004). Furthermore, many outcome or nursing
practice evaluation studies have been based on Donabedian’s structure–process–
outcome model. For example, the evaluation framework used by Yakimo and
colleagues (2004) is based on Donabedian’s model. These authors further explicated
their work in this field through a review of published studies. Similarly McCance
(2003) and Salzer and colleagues (1997) utilised Donabedian’s model in their studies
because this model emphasises a potential link between the three constructs on which
inferences can be drawn regarding quality.
According to Donabedian, this model was developed to assess clinical
practice. When the model is used to evaluate activities other than clinical practice, it
may be appropriate only if modified (Donabedian, 2003). For example, Hawkins and
Sherwood (1999) adapted this model to evaluate how an educational program
influenced the outcomes of programs. They integrated another program evaluation
model into Donabedian’s model to form their evaluation framework for continuing
education programs (Hawkins & Sherwood, 1999), as they focused not only on
outcomes of learning, but also on patient outcomes.
One benefit of Donabedian’s model is that it offers a predetermined
relationship between the three components, namely structure, process and outcome.
By using Donabedian’s model, the current study assumes that the structure of PHNs’
educational system will influence the educational processes, and better educational
process will improve educational outcomes subsequent to the program. In specific
terms, the structure of the educational system that the nurses are in will influence the
way in which the case management continuing education is implemented, which will
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in turn impact on the outcomes, including PHNs’ learning and case management
practice quality. With this in mind, a review of published articles about CPE
evaluation was undertaken (refer to Chapter Three) to understand the most effective
strategies for delivering this proposed intervention, factors influencing the
effectiveness of the program and the educational outcomes.
Donabedian’s structure–process–outcome model offers a macro view of
program quality and forms linear relations whereby structure influences program
process and then influences program outcomes. However, the simple linear
relationship between these three components may ignore some potential influencing
factors. Additionally, this model fails to identify the micro components of the
structure, process and outcome features.
The current study evaluates an educational program rather than health care
quality. Thus there was a need to expand this model by incorporating influencing
factors and three levels of educational evaluation components to guide the
development, delivery and evaluation of the CPE program. The selected research
design used a cluster randomised control trial to located PHNs to experimental or
comparison groups as an attempt to reduce the impact of potential influencing factors
not accounted for in the Donabedian model of quality evaluation.
4.4 STRUCTURE: FACTORS INFLUENCING THE
EFFECTIVENESS OF CCMCPE
The structure stage refers to three categories of factors affecting both the
process and the outcome of the CCME program. It includes the individual factors of
PHNs, educational factors and organisational factors identified from the literature
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(Alvarez et al., 2004; Cervero, 1985; Griscti & Jacono, 2006; Holton, 1996; Kruijver
et al., 2000).
4.4.1 Individual Factors of PHNs
Individual factors refer to the public health nurses’ personal characteristics
(Anderson, 2001; Kruijver et al., 2000; Melnyk et al., 2004), including age, highest
qualification in nursing, years in public health nursing and prior case management
training. From the literature reviewed in Chapter Three it emerged that the
relationships between individual characteristics and program effectiveness are not
currently clear. These individual factors were measured and included in the
demographic status section of the study.
Experimental and comparison groups were used in the study design,
incorporating pre- and post-tests using a cluster sampling strategy with random
allocation. Thus, the researcher attempted to control for external factors and thus
allow comparison across these individual variables. All registered public health
nurses in the health centres therefore had the same opportunity, and were either
allocated to the experimental or comparison group. Individual characteristics and
baseline data of knowledge, skills, and performance were measured to establish any
prior differences in these two groups before receiving the CCMCPE program.
4.4.2 Educational Factors
Educational characteristics refer to the characteristics of the educational
intervention, including how the program is designed, and what is provided. The
aspects of the educational factors, including needs assessment, program design,
learning materials, facilitator experience and effective strategies were considered to
influence the learning process, and hence influence the effectiveness of the program.
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The current study therefore carefully considered these factors during program
development.
Several different approaches have been shown to improve continuing
education outcomes in terms of knowledge, skills and behaviours. These positive
approaches include evidence-based or research-based educational practice (including
a comprehensive needs assessment to identify learning needs and knowledge gap), a
combination of learning strategies identified in case management education literature
(interactive lectures and small group discussions) and two learning strategies drawn
from transformative learning, and collaboration between nursing academics and the
workplace. These approaches were identified from the literature as potential factors
which could improve educational outcomes. They were therefore integrated into the
program development and delivery of the current study.
A needs assessment is one way of improving program effectiveness and
should include evidence from a range of sources to be most influential (Robertson et
al., 2003). Positive education outcomes are also associated with the use of gap-
analysis techniques (Davis et al., 1995). Hence a needs assessment, including a
review of written documents and focus group discussions, identified PHNs’ learning
needs and knowledge gaps. These findings then formed the basis of the program
design during development.
Program design itself is of utmost importance for the establishment of an
effective educational program. The current course design and development were
guided by an instructional planning process described by Lasley, Matczynski and
Rowley (2002). The basic components included identifying the instructional goals,
performance objectives, instructional strategies, models and materials, and the
performance assessment procedure. In order to consider the validity of the program
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design, an expert panel was used to examine the goals of the program, program
design, and the appropriateness of the program content.
Instructional experience and instructional materials were also carefully
considered and constructed in this study. Selecting a suitable facilitator with both
teaching experience and familiarity with case management was important. Quality
curriculum materials and a case management training manual were also designed and
developed by the researcher to guide the course delivery process. All the handouts
for each session, the timetable, learning plan, case study materials, guidelines for
learning activities, questions and issues for group discussions and references were
included in the case management training manual. The manual was used to guide
program delivery during the sessions and as a reference source for the participants.
4.4.3 Organisational Factors
Organisational characteristics refer to the context in which education or
training is implemented, or the organisational/situational characteristics. In this study
these factors included organisational support, resources, policies and standard
practice. That is, are there resources for staff in the workplace, and does the
organisational policy support staff to continuing learning? Are there learning
resources available in these centres? All the participants in this study were exposed
to the same continuing education policy and came under the supervision of Taipei
City Government. Therefore, there were similar policies, resources, and facilities in
different districts. The experimental group and the comparison group shared almost
identical characteristics and had very similar organisational factors.
Organisational support has in the past been identified as the most important
single factor influencing the effectiveness of continuing education (Stolee et al.,
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2005). Hence, the researcher obtained organisational support from the Health
Department of the Taipei City Government, the directors, and head nurses of each
health centre by presenting the proposed program and addressing their concerns.
Other considerations included equitable opportunities for all public health nurses to
attend, by providing the program during work time and in the workplace, disclosing
full information about the CCMCPE, and establishing no charge for attendance.
These steps should address the potential barriers to CPE described in the literature.
4.5 PROCESS: IMPLEMENTING THE CCMCPE PROGRAM
The CCMCPE program itself was developed based on two main factors, the
findings of the literature review, and an assessment of public health nurses’
educational needs garnered through focus group discussions. The case management
process, incorporating essential knowledge, skills and role activities for case
managers (as identified from the literature), formed the main content. Multiple
learning strategies, combined with learning strategies drawn from transformative
learning and case management education literature (interactive lectures and small
group discussions), were used to achieve multiple levels of outcomes, including
updating the knowledge and skills of case management and promoting changes in
participants’ stated practical performance. This transfer of knowledge and skills of
case management to participants’ practical performance was the main purpose of the
educational program. An educational theory explained the role of learning in
professional practice and the process by which learning and change occur (Mann,
2004). Hence, critical reflection and action plans drawn from transformative learning
were used to achieve transformation and link case management theory to case
management practice. Additionally, the public health nurses’ preferred learning
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methods were also identified through a needs assessment and integrated into the
program development and delivery
The collaborative partnership between public health nurses and academics,
and among the participating public health nurses, was a major feature of this study.
The facilitator, a member of academic staff, and the public health nurses worked
together to achieve the objectives of the proposed program. The role of the facilitator
was to design learning materials and promote the transition of learning from the
classroom to real practice. The role of the public health nurses was to share, discuss
their practical experiences and participate in the learning activities within the small
peer groups.
The six steps of the case management process provided the content
framework as literature supported the process as encompassing the main functions
and activities that case managers usually undertake. Essential knowledge, skills and
activities described in prior literature formed the detailed content. Evidence-based
effective strategies identified from case management education programs and two
transformative learning strategies were used to achieve desired multiple levels of
outcomes. All these features described above are known to help improve outcomes of
continuing professional education.
4.6 OUTCOMES: LEVELS OF EVALUATION
The literature review identified four levels of educational outcome evaluation,
and these have been described in detail in Chapter Three. These levels are Level I,
reaction evaluation; Level II, learning outcome evaluation; Level III, performance
outcome evaluation; and Level IV, patient outcome evaluation. This study
incorporated evaluation levels I to III, including participants’ satisfaction with the
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program (Level I), their knowledge level, performance confidence in case
management skills, preparedness level in case manager role activities (Level II) and
self-reported frequency of using case management skills, self-reported frequency of
using case manager role activities, and changes in case management practice (Level
III). The Level IV type of evaluation was not incorporated in the current study
because practical limitations prevented control of external factors.
Reaction evaluations provide useful insights into factors that contribute to
learner satisfaction, but do not directly measure the results of the training (Burrow &
Berardinelli, 2003). If training does not result in learning outcomes, training has no
value to an organisation (Burrow & Berardinelli, 2003). Determining the gain from
the learning is an essential measure, because learning from educational programs is
the foundation of transferring new knowledge and skills into work performance.
There is ample evidence that learning from education is often quickly lost or not
transferred to the job in a way that improves employee performance (Burrow &
Berardinelli, 2003; Czurylo et al., 1999). Therefore measuring participants’
performance after continuing education provide adequate evidence of the value of the
education to the practice or the organisation (Brunt, 2000; Burrow & Berardinelli,
2003; Dionne, 1996; Ger et al., 2004). Transfer performance involves behaviour
changes on the job as a result of education and can be assessed via post-tests after
education (Alvarez et al., 2004; Brunt, 2000). Hence, the reaction, learning and
performance levels of outcome evaluation should all be measured and indeed were
included in the current study.
Many authors agree that measures of improved organisational results or
patient outcomes (Level IV) are equal to, or more important than, an individual’s
work performance as a measure of the value of education (Furze & Pearcey, 1999;
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Stanard, 1999). However, many variables in addition to the effectiveness of
education, and typically beyond the control of training personnel, affect changes in
organisational performance or patient outcomes. As described in Section 3.1.2.2 of
Chapter Three, the lack of standardised case management practice and the fact that
public health nurses have different caseloads in different health centres impacted on
the ability of the researcher to assess patient outcomes following the education
program. It was impossible to measure whether variation in patient outcomes
stemmed directly from the educational intervention. Thus, evaluation of practice
changes after the educational program through focus group discussion was used to
gain an understanding of nurses’ behaviour changes following the program.
To summarise, Donabedian’s structure–process–outcome model offers a
macro view of program quality, depicting a linear relationship whereby educational
structure influences the educational program process and then better educational
processes improves the better outcomes of the educational program. Structural
factors influencing the program’s effectiveness were carefully assessed and
incorporated into the program development. Any individual differences before the
educational program were to examine. Different levels of outcome evaluation offer
indicators of the success of educational programs. This study measured Levels I to
III evaluations and focused on learner and practice changes.
4.7 LIMITATIONS OF THIS RESEARCH
Despite the obvious advantages of many of the features of the current study,
there were certain limitations. For example, time limitations prevented the
measurement of client outcomes. In addition, due to practical difficulties it was not
possible to make the researcher or the participants blind to the aims of the study, in
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order to prevent bias. The fact that no case management practice standards have been
established in Taiwan also means that there were no existing benchmarks available
for comparison, limiting some aspects of evaluating the program. A further limitation
was the risk that the participants (PHNs) would be too busy and lack the motivation
to initiate or continue with the program. This was a challenge for the investigator,
who used several strategies to overcome this potential problem. These strategies
included searching for support from health care organisations and administrators,
promoting the program in each health centre, and offering the program at times
convenient to the nurses.
4.8 SUMMARY
The theoretical framework of this study was based on an expanded version of
Donabedian’s (1992; 2003) structure-process-outcome evaluation model. By using
Donabedian’s model, the current study assumes that the structure of PHNs’
educational system will influence the educational processes, and a better educational
process will improve educational outcomes subsequent to the program. The current
model thus integrated individual, educational and organisational factors influencing
effectiveness into the framework, and also incorporated the three levels of outcome
evaluation identified from the existing evaluation models. The extended model was
then used to guide the development, delivery and evaluation of the CCMCPE
program to heighten its potential effectiveness.
There are several distinctive features of this program in terms of course
design, delivery and evaluation. The course content focused on the case management
process itself, including essential knowledge, skills and role-related activities to
prepare public health nurses to function in the case manager role. The results of a
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needs assessment and a literature review on evidence-based educational practice
guided the development of the CCMCPE program. Case management theory was
linked to case management practice with the aim of improving knowledge, skills, and
practice in case management by using a combination of learning strategies. Multiple
levels of evaluations (levels I to III) were incorporated in the program design, using
both qualitative and quantitative assessment methods. All of these features addressed
the deficits of existing evaluation studies of case management continuing educational
programs, and contributed to improving the method of assessing the effectiveness of
CCMCPE programs.
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CHAPTER FIVE
PHASE ONE: EDUCATIONAL NEEDS ASSESSMENT
5.1 INTRODUCTION
This study was divided into three phases and the detailed methods and results
of these three phases are described in the following three chapters. The present
chapter describes Phase One of the study, which consisted of a needs assessment
using focus group discussion to explore public health nurses’ educational needs in
case management. This chapter presents the research design, research questions,
focus group methods and qualitative data analysis for this phase. The results and
discussion is then presented at the end of the chapter.
5.2 RESEARCH DESIGN
Phase One of the study incorporated an exploratory design using a focus
group method. In this way qualitative data was gathered, allowing a needs
assessment to be conducted. The literature review revealed few previous studies have
been grounded on a needs assessment of participants when developing case
management educational programs. Furthermore, there has been little work
undertaken to date exploring Taiwanese public health nurses’ current case
management practice and their educational needs in case management. In order to
ensure the proposed educational program fitted PHNs’ educational needs, focus
groups were used to understand public health nurses’ concepts of case management,
their current case management practice and their needs in terms of case management
education.
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Focus groups are a method of interview designed for small groups which
allow the collection of qualitative data in a particular topic of interest (Berg, 2004;
Creswell, 2005). Focus groups provide a structured and organised method by which
valuable data can be gathered from relevant people. They provide more information
than surveys and enable the investigators to understand issues in depth (Sharts-
Hopko, 2001). In addition, focus groups are highly flexible, allow researchers to
assess views and opinions directly and they produce speedy results at low cost (Berg,
2004). The advantages of this method have led to focus groups becoming popular in
healthcare, nursing and educational settings to collect data and explore little-known
topics.
In educational research focus groups can be used to assist decision making
before a program is conducted. They are an efficient strategy for obtaining the views
of multiple individuals and are useful to elicit educational needs and preferences of
the local population before planning an educational program (Krueger & Casey,
2000). Focus groups have been used in other studies to assess nurses’ educational
and training needs (Kreitner, Leet, Baker, Maylahn, & Brownson, 2003; Sokol &
Cummins, 2002; Wood & Jacobson, 2005).
Several studies have used focus groups to guide the design of educational
programs (Ersek, Kraybill, & Hansberry, 2000; Fagerheim & Weingart, 2005;
Gebbie & Hwang, 2000; Kreitner et al., 2003; Wood & Jacobson, 2005). Kreitner
and colleagues recently used the findings of their focus groups to design a training
program for public health professionals (Kreitner et al., 2003). Gebbie and Hwang
(2000) conducted two focus groups to identify the skills needed by public health
nurses and understand the context in which they were required. This aided their
development of a collaborative program involving public health nursing practice and
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education. These authors noted focus group participants identified a number of
strategies that helped to make the educational program a reality and ensure its
content and approach matched the needs of trainees. Using focus groups is also
useful for preliminary exploration of certain topic areas in those fields where prior
research is lacking (Sharts-Hopko, 2001). For these reasons two focus groups were
conducted to explore the target research questions in the current study.
The decision to use two focus groups, conducted in two health centres in
Taiwan, was made on the basis of two main considerations. Firstly, the public health
nurses in each selected health centre reflected the target population, because they
were homogeneous in terms of gender, education level, work experience and prior
education in case management. Furthermore, the focus group or pilot study sample
participants were not included in the later evaluative study. Seventeen percent of
possible centres (two centres of 12) constituted the focus groups and can be
considered a reasonable sample size (Bloor, Frankland, Thomas, & Robson, 2002;
Krueger & Casey, 2000).
The research questions addressed within Phase One were:
1. What is public health nurses’ current knowledge of case management (CM)?
2. How do public health nurses practice CM?
3. What are public health nurses’ CM learning needs?
4. What are public health nurses’ preferred learning methods?
5.3 METHOD
Two focus groups were conducted in two health centres with the aim of
identifying the PHNs’ educational needs in relation to case management. The PHNs
of the two centres were not included in the later evaluation study. This section is
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comprised of three components—a description of the sampling and recruitment of
the focus group participants, a discussion of the moderation of focus groups, and a
description of the data collection procedures.
5.3.1 Sampling and Recruitment
The literature suggests participants who are potential consumers of a service
are valid members of a focus group. Each group should include six to ten participants,
although more should be invited in order to achieve the required numbers for
enrolment (Krueger & Casey, 2000; Sharts-Hopko, 2001). Participants for the focus
groups were recruited from cluster samples within the twelve health centres in Taipei
City. The two health care centres from which the participants were drawn for the
focus groups were selected randomly by a third party by picking two folded cards
from a collection of the names of the twelve health centres eligible for inclusion in
this study. The selected centres were District 1 with 12 public health nurses, and
District 2 with 18 nurses. The investigator invited all public health nurses in those
two health centres to attend separate focus group sessions. Potential participants in
the two health centres were eligible for inclusion in the focus groups if they:
1. had worked in the community health centres of Taipei City for at least six
months; and had engaged in care for at least one older adult living alone or a
patient with mental illness during this time (i.e., a head nurse not involved in
patient care would be excluded); and
2. had not received any training or education program about case management
during the three months prior to recruitment for this research.
The researcher managed the participant recruitment processes. Prior to
commencement, the researcher contacted the head nurses of the two districts by
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telephone and explained the purpose, time frame, and general procedures of the focus
group meetings. The head nurses subsequently arranged available times for the focus
groups and announced the meetings to all public health nurses in their district two
weeks in advance. At the arranged time the investigator distributed printed
information packages to each nurse attending the meetings. The researcher
introduced herself and then explained the study through the information sheets
(Appendix 1.1), noting the discussions would be tape recorded and that at least six to
twelve participants were expected. Additional reassurance was given that any
information provided would not be linked individually to participants in any report.
This confidentially was important as the nurses needed to feel assured they could
speak freely during the meeting.
After the researcher presented the introductory information and answered any
questions, those nurses who were interested in joining the focus group were asked to
provide written consent (Appendix 1.2). At this stage some of the nurses refused to
sign a letter of consent but nevertheless wanted to participate in the discussion. When
this occurred the researcher provided additional explanations emphasising there were
no risks inherent in the meeting. Those nurses who agreed and provided written
consent were invited to remain in the meeting room. Those who declined to join the
discussion were thanked for their time and returned to their work. After a short 15-
minute break, the discussion was held. The researcher conducted the same standard
procedures in the two health care centres.
A total of 16 public health nurses from two health care centres participated in
the focus group discussions, 8 nurses in each district. In District 1 recruited 12 PHNs,
9 nurses attended the meeting, one of which did not provide a written consent form.
The remaining 3 nurses were not able to attend because of prior commitments. In
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District 2 recruited 18 PHNs, 13 nurses attended the meeting, 4 of which did not
offer consent, and one of whom did not meet the selection criteria. Five additional
nurses were unable to attend the meeting. All the participants of the focus groups
were female and over 80% held a nursing diploma. Participants ranged in age from
28 to 51 years (M = 38; Median = 41) with experience in public health nursing
ranging from one to 25 years. Approximately 75% of participants did not have prior
training regarding case management. All participants in each of the two focus groups
contributed at least one comment throughout their session.
5.3.2 Moderation of Focus Groups
A typical focus group consists of a small number of participants under the
guidance of a facilitator, usually termed the moderator (Berg, 2004). The moderator
plays a key role in any focus group because a critical success factor is how well the
moderator leads the discussion (Davis, 2002; Patterson & Kelly, 2005). Moderating
requires both experience and moderating skills, therefore selection of a moderator is
very important. The experience and communication skills of potential moderators,
the sensitivity of the topic, and the time and money available are all factors
influencing moderator selection (Davis, 2002). In this current study the researcher
moderated the two focus groups herself. The reasons for this are described below.
First, the researcher had no prior working relationship with the nurses. Thus
the nurses should have felt they could talk freely and comfortably about their
understanding of case management and their current case management practice with
the researcher, as compared to a head nurse or a team leader from their health care
centre. A moderator also needs to be flexible and be able to adapt plans in response
to unexpected events, such as dealing with any conflict. The researcher, by virtue of
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her role as an unaffiliated third party, could appropriately deal with disagreement and
conflict issues within the focus groups.
The role of the moderator also includes listening to participant responses,
ensuring clarity of responses, encouraging responses, creating a comfortable
environment, managing expectations, keeping the discussion on track, making sure
everyone has a chance to talk and controlling the time during the discussion (Seggern
& Young, 2003). The researcher previously had training and experience in group
dynamics and communication skills and therefore could successfully lead the focus
groups, as the moderator contributes to facilitating the group interaction. Finally, the
researcher knew the project and was familiar with the topic of case management; this
background helped her to deal with issues raised during the discussion and to
establish a good rapport with the public health nurses (Seggern & Young, 2003).
For these reasons the researcher was used as the moderator in the focus
groups. The use of the researcher in this role had the potential to influence the results
to some degree as a social desirability bias is likely to occur in educational outcome
evaluation. However, it appeared the most logical choice given the researcher’s skills
and the context of the study. A set focus group discussion guide and standardised
data collection procedures were used to reduce any effect of the researcher acting as
the moderator.
5.3.3 Standardised Data Collection Procedures with Discussion Guide
Standardisation refers to the extent to which identical questions and
procedures are used for each group. The advantage of standardisation is that it allows
a high level of comparability across groups. Standardised data collection procedures
can facilitate the analysis of focus group data by allowing for direct comparisons of
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the discussions from group to group (Morgan, 2004). It can also reduce interviewer
bias and make data collection more objective. In order to standardise the data
collection procedures, a Focus Group Discussion Guide (Appendix 2.1) was
developed, based on several important principles identified from the literature (Bloor
et al., 2002; Morgan, 2004; Patterson & Kelly, 2005; Seggern & Young, 2003).
These principles included the following:
• The research purpose guides the interview questions.
• Interview questions are open-ended.
• Focus groups last between one to two hours in length.
• The discussions should be structured, beginning with introductions, followed
by an overview of the background of the study. The session should end with a
brief summary of the key ideas shared.
• A relaxed and conversational atmosphere encourages sharing of ideas.
• The moderator closely listens to participant responses, facilitate the group
interaction and clarify responses made by participants.
• A thorough transcription of the tape recording of the focus groups is required
in order to facilitate a detailed and rigorous analysis of the data.
These principles were logically integrated into the discussion guide
(Appendix 2.1). Several semi-structured interview questions identified from the
literature review were designed. There were four main topics that guided the focus
group discussions, namely case management concepts, current case management
practice, learning needs and preferred learning methods. An example of an interview
question is, ‘Can you talk about what you know about case management?’ A tape
recorder was used to record the group discussions and both the researcher and a
research assistant took notes during the discussions.
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The focus group discussions were held in a private meeting room within each
of the two centres to ensure the setting would be relaxed and comfortable for the
participants. All the participants were welcomed by the researcher and thanked for
their participation in the meeting. The printed discussion guide was given to the
participants. The researcher followed the discussion guide and first introduced
herself and then explained the purpose, procedure, time frame and general rules of
the discussion (e.g., speak clearly, only one participant to speak at a time). All of the
public health nurses at a single discussion worked in the same health care centre and
thus were familiar with each other, so it was not necessary to introduce the
participants to each other. Prior to the discussion, the researcher also encouraged all
the participants to talk freely, emphasised that there were no right or wrong answers,
and noted that they were to respect others’ opinions, as this is an important feature of
successful focus group discussions (Flick, 2002). The researcher then asked a small
number of general questions and elicited responses to those questions from all
individuals in the groups. All participants were encouraged to talk during the
discussion. Finally, all the key ideas shared during the discussion were summarised
by the researcher and confirmed by the participants.
The two focus group discussions lasted for approximately 60 minutes each.
These focus group interviews were then transcribed in Chinese and a professional
translation company translated the Chinese transcription into English. The data was
kept as a complete record of the discussion, facilitating analysis of the qualitative
data. For ethical considerations, all information collected was confidential and kept
in a locked filing cabinet, to which only the researcher had access.
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5.4 DATA ANALYSIS
This section describes the data analysis procedure, including the qualitative
data analysis methods and procedures.
5.4.1 Qualitative Data Analysis Method
Qualitative content analysis was used to analyse data obtained from the two
focus groups. According to Hsieh and Shannon (2005), qualitative content analysis
can be defined as a research method for the subjective interpretation of the content of
text data through the systematic classification process of coding and identifying
patterns. Qualitative content analysis is one of numerous research techniques of
analysing text data and focuses on the characteristics of language as communication,
with attention to the content or contextual meaning of the text. Text data for
qualitative content analysis can be obtained from focus groups (Kondracki &
Wellman, 2002).
There were several reasons for the selection of qualitative content analysis as
the data analysis method of the focus group data. Firstly, qualitative content analysis
is seen as an accepted approach to the analysis of focus group interview
transcriptions (Holloway & Wheeler, 2002; Sharts-Hopko, 2001). This method
enables the production of detailed and systematic core constructions from the textual
data through a process of reduction and analysis. Furthermore, qualitative content
analysis goes beyond merely counting words. It also examines and classifies text data
into an efficient number of categories that represent similar meanings. These
categories can represent either explicit communication or inferred communication.
Finally, qualitative content analyses are relatively inexpensive to perform, in terms of
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both the analysis itself and the generation of findings (Kondracki, Wellman, &
Amundson, 2002).
Of the different qualitative content analysis approaches, a conventional
content analysis technique was selected. Conventional content analysis is generally
used in the context of a study which aims to explore little known topics, for instance
when existing theory or research literature is limited (Hsieh & Shannon, 2005). This
approach is also useful if data is collected primarily through open-ended questions.
The current focus group discussions fit these criteria. The most notable feature of this
approach is that coding categories are derived directly from the text data (Hsieh &
Shannon, 2005). During the conventional content analysis, some principles adapted
from the literature were identified and applied in the analysis of the focus group data.
Four main principles were applied in the data analysis. Firstly, the researcher
analysed the information from the two focus groups separately and then integrated
the results in order to produce the findings. This allowed examination of the data
both within and between groups, as is desirable with focus group data analysis
(Graneheim & Lundman, 2004). The researcher used the Chinese transcriptions to
analyse the focus group data because she is a native Chinese speaker. Another
researcher (a native English speaker) read through the English version of the
transcriptions and identified categories.
Discovering themes is the basic task when analysing text. The first pass at
generating themes often comes from the questions in an interview protocol (Morgan,
2004). Hence, four main themes of the transcriptions emerged from the target
questions. These were the understanding of case management, current case
management practice, learning needs, and the preferred learning methods of public
health nurses. Finally, content analysis is an interpretative process whereby the
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researcher identifies, codes and categorises the descriptive data (Graneheim &
Lundman, 2004; Hsieh & Shannon, 2005). The researcher thus identified, coded and
categorised the transcription data, with all of the coding categories emerging from
the text data.
The analytical method used to analyse the focus group data was based on the
procedures described by Burnard (1991), and Graneheim and Lundman (2004). The
stages of qualitative content analysis described by Burnard (1991) provide systematic
processes and step-by-step procedures enabling rigorous qualitative data analysis.
The method seeks to obtain meaning and understanding from the data (Burnard,
1991).
5.4.2 Procedures of Qualitative Content Analysis
This study applied the 14 stages of content analysis (shown in Table 5.1)
described by Burnard (1991, p. 462–464). However, this method lacks definition of
terms and detailed procedures describing how to produce codes, subcategories and
categories. Thus the processes described by Graneheim and Lundman (2004) were
also used, as they detail appropriate concepts and procedures and describe how to
achieve trustworthiness. Hence, the analysis was guided by these two main
references (Burnard, 1991; Graneheim & Lundman, 2004). The stages of data
analysis and definitions as used in this study are outlined in Table 5.1. The 14 stages
are generally divided into four main domains: data preparation and familiarity;
confirmation of categories and subcategories; achieving trustworthiness through the
transcriptions; and write up of findings.
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Table 5.1
Stages of qualitative data analysis
(adapted from Burnard, 1991; Graneheim & Lundman, 2004)
Stages Description Adapted description and term definition
Stage 1 Notes are made after each interview, as well as memos about ways of categorising the data.
Notes are made during the focus groups sessions.
Stage 2 Transcripts are read through and notes made throughout the reading on general themes within the transcripts.
Transcriptions were translated into English. A theme refers to threads of meaning that recur in domain after domain. The concept of theme is also used. Generally, themes can be viewed as target questions because the interviews are well-structured and topic-oriented. Hence, the text is sorted into four content areas with four themes targeted.
Stage 3 Transcripts are read through again and as many headings as necessary are written down to describe all aspects of the content. This stage is known as “open coding”. Categories are freely generated at this stage.
Unit of analysis is whole interviews. Parts of the text (words, phrases, sentences or paragraphs) written in the transcript text, that are abstracted and coded (Graneheim & Lundman, 2004).
Stage 4 The list of categories is surveyed by the researcher and grouped together under higher headings.
A category refers mainly to a descriptive level of content and can be seen as an expression of the meaning content of the text and it can be identified as a thread throughout the codes (Graneheim & Lundman, 2004). The various codes are compared based on differences and similarities and sorted into subcategories (Graneheim & Lundman, 2004).
Stage 5 The new list of categories and sub-headings is worked through and repetitious or very similar headings are removed to produce a final list.
A category often includes a number of subcategories at varying levels of abstraction. The subcategories can be sorted and abstracted into a category or a category can be divided into subcategories (Graneheim & Lundman, 2004).
Stage 6 Two colleagues are invited to (independently) generate category systems.
Two researchers separately analyse the text data to identify categories and then the categories are discussed by the two researchers and revised (Graneheim & Lundman, 2004).
Stage 7 Transcriptions are re-read alongside the final agreed list of categories and sub-headings to establish the degree to which the categories cover all aspects of the interview. Adjustments are made as necessary.
As described at left.
Stage 8 Each transcription is worked through with the list of categories and sub-headings and coded according to the list of categories headings. Coloured highlighting pens can be used here to distinguish between each piece of the transcript allocated to a category and sub-heading.
Italic font was used to distinguish between the two focus groups.
Stage 9 Each coded section of the interviews is cut out of the transcript and all items of each code are collected together.
As described at left.
Stage 10 The cut out sections are pasted onto sheets, grouped by the appropriate headings and sub-headings.
As described at left.
Stage 11 Selected respondents are asked to check the appropriateness of the category system.
The researcher invited a colleague to read the transcripts and to identify a category system. A process of reflection and discussion resulted in agreement as to how to sort the codes. Finally, the categories were formed into the themes of targeted questions (Graneheim & Lundman, 2004).
Stage 12 All the sections are filed together for direct reference when writing up the findings.
The researcher wrote up the findings following the results tables with categories, subcategories and selected respondents’ quotes.
Stage 13 The researcher starts the write up process with the first section and offers a commentary that links the examples together.
As described at left.
Stage 14 The researcher must decide whether or not to link the data examples and the commentary to the literature. The researcher may write up the findings, using verbatim examples of interviews to illustrate the various sections. The researcher may then write a separate section which links those findings to the literature on the topic, contrasting and comparing.
The researcher decided to write up the findings and link those findings to the literature on the research questions.
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The first three stages of Burnard’s 14 stages relate to data preparation and
familiarity. The focus group discussions were transcribed from the tape recordings in
Chinese by the research assistant on the same day as the discussions. These
transcriptions were checked immediately by the researcher against the notes taken
during the session by the researcher and the research assistant. A professional
translation company subsequently translated the Chinese transcripts into English.
The researcher then reviewed the two transcriptions, confirming that they were
identical. These two sets of complete raw data in English and in Chinese were used
for the content analysis and kept as a complete record of the focus group discussions
(Appendix 2.2).
The researcher read through the transcripts in Chinese several times to
become familiar with them. Notes were made after each transcript, as well as memos
about ways of grouping the data. As the interviews were well-structured and topic-
oriented the themes were viewed as the target questions, hence the text was sorted
into four content areas with four themes targeted.
Confirmation of categories and subcategories through the transcriptions
comprised stages 4 to 6 (refer to Table 5.1). Transcripts were read through again and
as many codes as necessary were constructed in Chinese to describe all aspects of the
content – known as the coding process. The basic coding process in content analysis
involves organising large quantities of text into fewer content categories. Parts of the
text (words, phrases, sentences or paragraphs) were abstracted and coded
(Graneheim & Lundman, 2004). Then, the various codes were compared based on
differences and similarities and sorted into subcategories (Graneheim & Lundman,
2004).
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Subcategories were then freely generated into categories. A category refers
primarily to a descriptive level of content and can be seen as an expression of the
meaning of the content of the text. It can be identified as a thread throughout the
codes (Graneheim & Lundman, 2004). Categories are also patterns that are directly
expressed in the text or are derived from them through analysis (Hsieh & Shannon,
2005). The researcher then organised each theme (target question), categories,
subcategories, and codes into one table to form the first draft. In order to confirm the
categories and subcategories identified by the researcher, another researcher was
invited to independently generate category systems. The researchers searched for
agreement through reflection and discussion to establish the agreed list of categories
and subcategories.
Following identification of the category systems, the researcher applied
stages 7 to 11 (refer to Table 5.1) to achieve the quality and validity of the data
analysis, usually referred to as trustworthiness. The researcher separately analysed
the two focus groups and then integrated the results to produce the findings. The two
transcriptions were worked through using the list of categories and subcategories and
coded according to the category headings. Adjustments were made as necessary.
Italic font was used to distinguish between the two focus groups. The researcher then
created four tables according to each target research question. Each coded section of
the transcriptions was cut out and all items of each code were collected together in
the table under the target questions.
The last three stages guided the researcher in writing up the findings. The
researcher integrated the four tables according to the four target research questions
into one final results table (refer to Table 5.2). The researcher then wrote up the
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findings and linked those findings to the literature to form a solid evidence base for
the program design. The results and discussion are presented in the following section.
Table 5.2
Categories of the focus groups (needs assessment)
Themes Categories and subcategories
Current case management knowledge
Managing abnormal cases • Helping listed clients • Abnormal cases with 3H1 diseases, elderly living alone and
mentally ill patients No idea • Not clear • Different from hospital CM
Current case management practice
Management activities • Assessing/ implementing/ monitoring/ follow up
Educating clients • Providing knowledge, health education, health promotion,
health seminars, health prevention Working with others • Social workers; organisations; families and individuals
Learning needs What is case management
• Have not learned before • No training
Complete framework • Whole picture of the case management framework • Teach us complete contents
Preferred learning methods
Interesting • Teacher delivery • Add our experiences • Make changes during course
Effective • Apply to our current practice • Match teaching with experiences
3H1 diseases refer to high blood sugar, high blood-lipid, and high blood pressure.
5.5 RESULTS AND DISCUSSION OF FOCUS GROUPS
This section presents the results of the two focus groups conducted to assess
public health nurses’ understanding of case management (CM), their current practice
related to CM, and their learning needs and preferred learning methods. This
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assessment took place prior to planning a collaborative case management education
program. The results comprise four main sections according to the four research
questions. The categories and subcategories of the four research questions are
detailed in Table 5.2.
5.5.1 Current Case Management Knowledge
Participants in the focus groups were asked to describe their knowledge of
case management. Two main categories were identified: ‘managing abnormal cases’
and ‘no idea’. The participants viewed case management as a means of managing
abnormal cases. They noted that case management was for helping listed clients.
Some participants discussed abnormal cases, particularly referring to those with 3H
(high blood sugar, high blood-lipid, and high blood pressure), the elderly living alone
and mentally ill patients. The following are quotes from participants regarding these
issues.
In principle, case management is to list cases’ names and manage
them, in which certain arrangements are made for abnormal cases.
We can see if there are things that we can help with.
We look at any abnormalities and place our emphasis on the
management of cases.
We do case management for abnormal case. Most of the targets of
case management are the cases of 3H, elderly living alone and
mentally ill patients in our areas.
In addition, some participants indicated honestly that they had ‘no idea’ what
case management really was and stated they could not talk about the meaning of case
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management because they did not have prior training regarding case management.
Participants were not clear about case management concepts and what their role is in
case management. Some of them stated it seemed to be different to case management
in hospitals, but they could not describe exactly what the differences were. The
participants made the following comments.
We have no idea what case management is really about.
I cannot express any meanings regarding CM, so I need to attend
courses.
We do not understand the core and concepts of CM
I do not have a clear understanding about my roles in CM
It is somewhat different from the one in hospitals.
To my understanding, case management in hospitals focuses on
specific diseases, whereas we cover all categories of diseases.
There is little literature available that can be used as a basis for comparison
with these results because this study was the first on this topic in Taiwan. According
to the Commission for Case Manager Certification’s survey for case managers in
America, the case management concepts domain is one of the essential knowledge
arenas for case management practice (Tahan, Downey & Huber, 2006). Case
management concepts address the knowledge of the process of practice and methods
of establishing quality measures (Tahan et al., 2006). However, the public health
nurses interviewed in the current study discussed only a small component of the
process of case management, and some stated that they had no idea about case
management concepts at all. Thus these findings reveal that the participants had
limited knowledge and lack clear and systematic conceptual knowledge regarding
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case management. The information from the focus groups supports the notion that
additional education was needed for public health nurses to improve their
understanding of the case management process and clarify these nurses’ roles in case
management practice.
5.5.2 Current Case Management Practice
In relation to current case management practices, three categories were
identified from the focus group discussions: ‘educating clients’, ‘management
activities’, and ‘working with others’. Some participants primarily discussed
‘educating clients’ and seemed conceive to this as their main task related to case
management practice. They said they provided knowledge, health education, health
promotion, and health prevention seminars to cases. This is reflected in the following
quotes.
We need to provide him with some knowledge for him to understand.
We perform health education, seminar, and screenings…etc.
We focus on health promotion and preventions.
We invite them (cases) to participate in our seminars or activities of
health promotion.
Another category referred to ‘management activities’. Within case
management practice, the public health nurses conducted assessing, implementing,
monitoring and follow up for their cases.
We observe his or her knowledge, attitudes, behaviour toward his or
her food habits, look at any abnormalities.
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We do things like understanding if these cases take medications
regularly and provide common screening and health education.
We also see if there are resources that allow referrals for the cases.
‘Visit the cases and measure their blood pressure’
Follow-up management is needed if patients are transferred to other
hospitals or are hospitalised.
In addition, the participants mentioned ‘working with others’, including
social workers, organisations, families and individuals.
Case management also includes the parts that we are less capable of,
such as helping solitary seniors. We work with social workers or
other organisations to help families and individuals.
We also see if there are resources that allow referrals for the cases.
Overall, the current case management practice of Taiwanese public health
nurses focused on providing health education and conducting some management
activities. By contrast, CCMC’s study of case managers in America identified six
essential activity domains of case management practice. These essential activities
were defined as case finding and intake, provision of case management services,
outcomes evaluation and case closure, utilisation management activities,
psychosocial and economic issues, and vocational rehabilitation activities (Tahan et
al., 2006). Service content may differ among health care settings and countries.
Compared with these descriptions, however, Taiwanese public health nurses only
partially used the case management process and related activities in their work. They
did not include the activities such as case finding and identification of high-risk cases,
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and evaluation the outcomes of case management. Hence, educational preparation for
case management process and related activities is necessary in order to help public
health nurses to function better as case managers and improve their case management
practice. These aims thus form the main goals of this educational program.
5.5.3 Learning Needs
In terms of learning needs, there were two main categories identified from the
analysis: ‘what is case management’ and ‘complete framework’. The participants
wanted to learn exactly what case management ‘is really about’, and they spoke of
their wish to obtain a more complete picture of the principles and framework of case
management. Participants also sought a clear understanding regarding case
management, which most were lacking because they had no prior training about case
management. Public health nurses stated they did not understand the core or the
framework of case management and they wanted to get the complete picture of case
management theory and practice. The following quotes reflect this.
We have no idea what case management is really about, we have not
learned about case management before, so we do not understand the
core picture of case management.
Basically, we seldom have any education and training that teaches us
how to do case management.
We are not very clear with what case management is and what its
concepts and frameworks are.
Please teach us the complete concepts as we want to learn the
complete content.
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No other specific topics were mentioned in the focus groups. However, a
limited understanding of case management may well explain the limited topics
identified from the focus group interviews. What case management is and the
complete framework of case management were the targets of their learning needs.
Generally, the required topic area refers to the foundational concepts of case
management as described in the literature. Literature supporting the case
management process can be seen as a practice framework of case management. This
could fit the participants’ educational needs in terms of providing comprehensive
content in this field. Hence, essential knowledge and skills of the case management
process may fit their case management education needs and help them to function as
nurse case managers. The results of this study provided evidence as to what content
was needed in the program. Thus, essential knowledge, skills of case management
and case management process related activities formed the main content framework
of the implemented educational program.
5.5.4 Preferred Learning Methods
Overall, there was no single preferred learning pattern or learning methods
identified by the participants. However, the participants said they wanted
‘interesting’ and ‘effective’ methods. The meanings of these two terms were
furthered explored and interpreted according to the other information offered in the
focus groups. The word ‘interesting’ related to ‘teacher delivery’, ‘add our
experience into the course’ and also to ‘make changes during course’. Participants
indicated they would like the teacher to deliver and lead the course and then allow
them to discuss the concepts of CM in relation to their experience in practice. They
also wanted the education program to be flexible with the ability to modify delivery
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mode if required during the course. The example statements by participants below
reflected this.
It’s (education) better to be interesting and effective and we can apply
it to our current practice.
In principle, it depends on how the teacher leads the course, and we
will see what improvements are needed during the processes.
I think the teacher can first talk about the basic concepts and
framework, and then we will add in our experiences from actual
practice for discussion.
The word ‘effective’ as used by participants referred to ‘apply our current
practice’ and ‘match teaching with experience’. They talked about the need to apply
their current experience within the educational program. Participants also indicated
that it was better to match the teaching with their experience and current practice.
I wonder if (you) can teach us effective case management.
We wish that the methods used in teaching us what case management
is can be matched with our experience.
Hence, the public health nurses seemed to prefer multiple learning strategies,
with a combination of traditional teacher lecturing sessions about basic concepts and
non-traditional group discussion using their real work experience. To some degree,
the results are consistent with Kuo’s studies and those by Lee and colleagues (Kuo,
2003; Lee, Chen & Lee, 2001). Kuo conducted a needs assessment for a health
promotion training program for public health nurses in the Hualien and Taitung
counties of Taiwan (Kuo, 2003). He found that role play, group discussion and
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demonstration were the most welcome methods. Lee et al.’s survey revealed that
linking course content to experiential learning was listed favourably by students (Lee
et al., 2001). These methods have similar features in that they link work experience
to learning and make education more interesting.
However, Kuo’s participants did not stress the importance of lecturer-based
methods such as teacher delivery. This may be because health promotion concepts
were not new for them, as case management was for the current study participants.
This interpretation is supported by literature that shows lectures often prove useful
for introducing new topics or concepts and are a useful strategy for the development
of fundamental knowledge and skills for teaching (Chiappetta, 2006).
The use of multiple learning strategies to achieve expected outcomes has
repeatedly been identified as a popular and successful way of learning. Many
educators have combined lectures and group discussions to conduct case
management education (Dickerson & Mansfield, 2003; Fletcher & Coffman, 1999;
McClaran, Lam, Franco, & Snell, 1999). Therefore, the participants’ preferred
learning methods, as identified from the focus groups, were integrated into the
current study’s educational program. Strategies that matched their expectations were
used to potentially improve the effectiveness of the proposed program, including
interactive lectures and group discussions.
In reviewing the findings, generally the participants within the focus groups
had a limited understanding of case management and lacked knowledge about the
concepts involved. Their current case management practice focused on health
education, management activities and working with others. They partially used the
case management process and yet their case management practice lacked theoretical
guidance. They said they did want to learn about case management, particularly what
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it really involved and to gain a complete picture of the framework of case
management. Participants stated they wanted the teacher to deliver related concepts
first, and then have the opportunity to add their experiences to the discussion. They
would like the ability to make changes, if necessary, during the course.
The findings overall support additional education to enhance public health
nurses’ understanding of case management concepts and process, and to improve
their case management practice. The data from the focus groups also offered clear
directions for planning and developing a collaborative case management education
program for public health nurses. The information from this study formed the
foundation for the next phase of the study – educational program development.
Phase Two used the findings of the needs assessment to develop a case
management education program. The program development and pilot testing of the
initial educational program and instruments used in the study are discussed in
Chapter Six. The evaluation of the developed educational program will be described
in Chapter Seven.
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CHAPTER SIX
PHASE TWO: PROGRAM DEVELOPMENT AND PILOTING
Phase Two of the study involved the development and piloting of a
collaborative case management continuing professional education program based on
the information collected in Phase One. This chapter describes the methodology and
findings of Phase Two in which an educational program was developed, reviewed,
and tested. The program underwent initial development, expert panel review and
pilot testing of various improvements. The psychometric properties of the
instruments used in this study were also examined during this stage.
6.1 INITIAL DEVELOPMENT OF INTERVENTION
The initial development of the collaborative case management continuing
professional education (CCMCPE) intervention program was grounded in the
findings of an extensive literature review and a needs assessment (including the
results of Phase One). These steps identified the different program components
required by Taiwanese public health nurses, isolated essential content, and generated
effective strategies to maximise the effectiveness of the program. Using these
findings, the researcher then developed the course plan and learning materials by the
identification of goals, objectives, content, strategies and materials, and the
organisation of assessment procedures (Lasley, Matczynski & Rowley, 2002).
6.1.1 Findings from the Literature Review
Case management can be defined as a service delivery process that consists of
a set of steps and activities applied by case managers – the case management process
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delineates the roles and responsibilities of case managers (Cesta & Tahan, 2003).
Each step in the process requires case managers to exhibit specific skills. The
combination of these skills enables the successful performance of the case manager
in related role activities.
Regardless of the care setting, providing a case management service can be
separated into six main activity domains of case management practice, which have
been identified according to the six steps of the case management process. These are
case finding and intake, assessment and problem identification, provision of case
manager services, care coordination and referrals to other health care providers,
ongoing assessment and monitoring, and outcome evaluation and case closure. These
specific case management activities can be seen as the core functions and
responsibilities of case managers because they are performed during the whole case
management process (Cohen & Cesta, 2005a; Goodwin, 1994; Lusky, 1995; Powell,
2000). In order to prepare nurses to act as case managers, education that includes
essential knowledge, skills, and role activities of case management should be
undertaken.
Chapter Two identified essential knowledge and skills required to be a
successful case manager. Knowledge required to be a case manager consists of the
following: a definition of case management, case management from a historical
perspective, purposes of case management, case management models, case
management processes, case management tools, community resources relevant to
case management, and service coordination and referrals (Chan, Leahy, McMahon,
Mirch, & DeVinney, 1999; Joshi & Pedlar, 1992; Powell, 2000). These content areas
are treated as foundational knowledge for new case managers while the public health
nurses may already have some knowledge of these. Hence, the needed content and
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knowledge gaps identified in the needs assessment were addressed to fit their case
management educational needs. In addition, nurse case managers need to have a
specific set of skills in order to perform case management practice and carry out their
clinical and professional responsibilities. These skills can generally be described as
clinical case management skills, communication skills and leadership skills (Cesta &
Tahan, 2003). Nurse case managers need to be competent in the essential skills of
comprehensive client assessment, case management planning, client referral to
resources, implementation of case management planning, monitoring of services and
client progress, evaluation of client outcomes, communication skills in customer
relations and interviewing, and leadership skills in advocacy, negotiation,
collaboration, critical thinking and problem-solving (Lenburg, 2005; Powell, 2000;
Powell & Ignatavicius, 2001). All of these skills are needed to function effectively in
a case management role. The identification of these essential knowledge bases, skills
and activities provided a basis for the content framework of the case management
training program.
6.1.2 Results from the Needs Assessment
Previous literature emphasises the importance and significance of needs
assessment for the establishment of new education programs. The development of
the current program incorporated the findings of a needs assessment. Under the
proposed research framework (described in Chapter 4), there are three key domains
that need to be carefully assessed, as they influence both the process of the program
and its subsequent educational outcomes. These domains are learner factors,
organisational factors and training factors.
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6.1.2.1 Assessing Learner Factors
The learner factors regarding case management concepts and current case
management practice were assessed using the focus groups. In this way the learners’
(PHNs’) gaps in knowledge and practice could be identified. The learners’
educational needs in case management and their preferred learning methods were
also explored through the focus group discussions. As described in Section 5.5.1,
most public health nurses who took part in the focus groups had only a limited
understanding of case management, probably due of a lack of appropriate education.
The PHNs in the focus groups engaged with chronically ill patients, mentally
ill patients and older adults living alone in the community using case management
techniques. Generally, their case management practice lacked theoretical guidance,
as evidenced by the fact that the processes of case identification, identifying
available resources, and evaluation of case management outcomes were not
mentioned by participants during the focus group discussions. That is, the nurses
only partially used the case management process in their daily case management
practice. However, focus group participants expressed a specific interest in
expanding their understanding of core case management concepts. The nurses also
described their difficulties carrying out case management practice for mentally ill
patients. They attributed this to their unfamiliarity with case management concepts
and the fact that it was a relatively new work task.
These descriptions highlighted the PHNs’ gaps in knowledge and practice
regarding case management, and supported the need for case management education.
It was clear that education was required to improve the nurses’ knowledge of the
case management process, as well as their understanding of case management
theory-based practice. The case management education program that emerged from
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the current research thus aimed to provide Taiwanese public health nurses with the
essential knowledge and skills of case management in order to achieve successful
theory-based practice in the community. The underpinning motivation for this
education was the hope that it would ensure successful case management practice
and hence contribute to better patient outcomes.
6.1.2.2 Assessing Organisational Factors
In terms of organisational factors, educational policy, available resources,
standard case management practice, and organisational support were all identified
and investigated as factors which contribute to ensuring better educational outcomes.
All the public health nurses followed the same educational policy, as they are
supervised by the Department of Health in Taipei City. In order to improve their
professional development, all public health nurses must receive at least 20 hours of
continuing education annually. In addition, each health centre has full resources and
facilities for education and training, consisting of a large teaching room, tables and
chairs, teaching aids such as PowerPoint™ computer facilities, and a whiteboard.
Standardised case management practice offers descriptions of nurses’ roles
and functions in case management practice. Standardised case management practice
for the Taiwanese public health nurses was not established at the time this study was
initiated. In other words, the public health nurses of the 12 health centres were in the
same situation in that they practiced case management work in different ways across
each district. The lack of standardised case management practice impacted on the
assessment of patient outcomes following the education program. This is because it
was impossible to measure whether variation in patient outcomes stemmed directly
from the educational intervention. Another organisational issue related to the
difficulty of actually measuring nurses’ behaviour change because the nurses usually
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conducted home visits around Taipei City. There was also a potential for public
health nurses to refuse to take part in this study because of perceptions that it may
compromise patient privacy and the nurses’ own autonomy. Thus, evaluation of
practice changes after the educational program through focus group discussion was
used to gain an understanding of nurses’ behaviour changes following the program.
Organisational support also plays an important role in continuing education,
in this particular context because the organisation’s support was required in order for
staff to attend the program in their working hours. The researcher used some
strategies to gain organisational support, including presenting this project to the
Taipei City Government and visiting the directors and head nurses to clarify their
concerns. Another important strategy working in favour of this program was that the
nurses’ contact hours for this education program could be added into their annual
continuing educational hours.
6.1.2.3 Assessing Educational Factors
In the program framework, educational characteristics are conceptualised as
one of the key structural factors for the success of education programs. Educational
characteristics refer to the characteristics of the intervention, the validity of the
program design and the effectiveness of strategies, the qualifications and experience
of the facilitator, and the learning materials used. All of these issues may have an
impact on educational outcomes (Alvarez et al., 2004; Cervero et al., 1986;
O'Loughlin, 2002).
As described in Chapter 2, current literature suggests that collaboration
between the academic setting and practice is a growing trend, and is a better strategy
in terms of preparing working nurses for case management practice because of its
multiple benefits. Limitations within education courses in Taiwan are similar to those
150
in other countries, in that it is often difficult to find suitable clinical experiences and
role models when teaching case management in nursing education (Haw, 1996).
Collaboration between public health nursing practice and nursing academics offers
an opportunity for the two fields to learn together.
The facilitator created an open learning atmosphere, encouraging participants
to join in the learning activities, providing feedback on their performances and
evaluating participant effects. In addition, the facilitator focused on acting as a
collaborative partner with the PHNs and helping to link case management theory
with the nurses’ real case management practice. The researcher was the main
facilitator of the program because of her background, qualifications and experiences.
Prior to the program the researcher had undertaken substantial training in case
management theory, educational theory and practice, with work experience both in
the community health and community mental health settings. Thus the researcher
was suitably qualified to manage the education program. The use of a single
facilitator assured a standardised educational intervention processes and eliminated
the potential for between-instructor effects.
The researcher’s dual roles as both the researcher behind the program and the
program facilitator might affect the study findings. For example a potential effect
may be social desirability in the program evaluation conducted through focus group
discussions. However, the researcher was aware of this both due to her qualifications
(discussed above) and because of the difficulties finding another facilitator with
clinical experience in implementing case management (or a nursing educator trained
in case management). In the educational environment in Taiwan, most nursing
academics act in both as educators and researchers because the national educational
department in Taiwan uses these domains to assess the performance of college and
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university teachers. It can thus be a challenge for the researcher/facilitator to remain
objective during the reality of the work environment, and this could be a limitation of
the current study. The standardisation of data collection procedures and strategies
used to achieve trustworthiness of the results from the focus groups had been
carefully considered in Phase One as well as the focus group discussions after
program delivery in Phase Three.
In terms of program content, the case management process, with its six steps,
formed the content framework of the present CCMCPE program. During the
development process, essential knowledge and skills needed for case managers to
successfully fulfil their roles were identified from the literature, as described in the
previous section. These particular types of knowledge, skills and related role
activities formed the content framework of the program. In addition, well-designed
learning materials can improve the effectiveness of learning, and thus a learning
manual was developed by the investigator to guide the program delivery.
In terms of effective learning strategies, prior literature provides evidence that
multiple learning strategies are more effective than single strategies (Robertson et al.,
2003). Interactive lectures and group discussions are regarded as effective learning
strategies in case management education (Dickerson & Mansfield, 2003; Howell et
al., 2004; McClaran, Lam, Franco, & Snell, 1999). Literature also supports using
transformative learning strategies (critical reflection and action plans) to help
learners to change their perspectives and transfer their practice (Cranton, 2002;
Melnyk et al., 2004; Mezirow, 2000). This information underpinned the delivery
strategies of the proposed education program. Hence a range of strategies were
selected to fit public health nurses’ preferred learning methods, achieve better
educational outcomes and practice changes.
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There were four main strategies selected in the current educational program.
Games were used to motivate and introduce the PHNs to the topics, explore their
current knowledge, and fit with their preferred interesting learning methods. Short
interactive lectures were used to effectively update PHNs’ knowledge and skills in
relation to case management because, for the most part, the concepts of case
management were relatively new to the nurses, so a short lecture was seen as
appropriate (Cohen & Cesta, 2005a). Additionally, an interactive lecture strategy also
fitted with the PHNs’ preferred learning methods.
Reflection and action plans drawn from transformative learning were used to
achieve active practice changes. Transformative learning regards learning as a
reflective process, therefore by using reflection on current practice through guided
group discussions within designed activities, the learners can link concepts learned in
the classroom to their real practice and their prior experience (Cranton, 2002;
Mezirow, 2000). This reflective strategy through group discussions also fitted the
PHNs’ preference of linking learning to their prior experience and public health
nurses can collaborate together to reflect their practice and experience. The last
strategy was using action plans to integrate learning in the classroom to their practice.
In this way, the learners had an opportunity to practice activities and skills learned in
the classroom to their daily work (Cranton, 2002; Mezirow, 2000).
6.1.3 Initial Program Development
The findings from the literature review and integrative needs assessment,
including the results from Phase One, formed the foundation for the development and
design of the educational program in Phase Two. Based on the evidence presented in
the previous section, the researcher used the process of instructional development to
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design and develop the learning materials – including the identification of goals,
objectives, strategies and materials, and evaluation methods (Lasley, Matczynski &
Rowley, 2002). This process resulted in the logical design of a case management
education program. The initial program plans produced are depicted in Table 6.1.
The program was titled the Collaborative Case Management Continuing
Professional Education Program (CCMCPE). This education program sought to
foster collaboration between case management practice and nursing academia, and
within public health nurses. Public health nurses and a nursing academic cooperated
to learn about case management. The researcher acted as a learning facilitator to help
learners achieve their desired goals and objectives.
The two key goals of this program were to prepare public health nurses in
case management theory and practice, and to achieve theory-based guided case
management practice in their roles as case managers. In order to achieve these aims,
detailed objectives were set up. By the end of this 16-hour course, all participants
were expected to have:
1. Explored their current understanding of case management
2. Reviewed case management concepts and the management process
3. Practised case management skills in teams
4. Reflected on the differences between current practice and case management
theory
5. Examined their experience and criticised their current practice
6. Developed possible strategies for problem solving in their practice
7. Written planned action activities
8. Actioned planned skills and case manager activities in their workplace.
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Table 6.1
Initial Case Management Education Program
Program Collaborative Case Management Continuing Professional Education Program Background Public health nurses require preparation for acting in case manager roles to
meet the changes in the health care delivery system Participants Public health nurses (PHNs) in health centres of Taipei City Goals 1. Prepare PHNs in case management theory and practice
2. Achieve theory-based guided case management practice Objectives By the end of this 16-hour course, all participants will have:
1. Explored their current understanding of case management 2. Reviewed case management concepts and the management process 3. Practised case management skills in teams 4. Reflected on the differences between current practice and case
management theory 5. Examined their experience and criticised their current practice 6. Developed possible strategies for problem solving in their practice 7. Written planned action activities 8. Actioned planned skills and case manager activities in their workplace
Content 1. Case management concepts and process 2. Case management skills, communication skills and leadership skills 3. Case manager role activities 4. Specific case management practice (Details see Table 6.2)
Facilitator The researcher Sessions Total of 16 hours, comprising four half-day sessions;
one every two weeks; 1:30pm-5:30pm The Site Teaching rooms at health centres in Taipei City Learning Strategies and activities
Four types of learning activities: 1. Inductive learning activity-explore strategy
A learning activity that connects learners with what they already know and with their unique context
2. Input learning activity-Interactive lecture strategy A learning activity that invites learners to examine new input (concepts and skills) - the content of the course
3. Implementation activity-critical reflection strategy A learning activity that gets learners to do something directly with new content and implementing it.
4. Integration learning activity-action plan strategy A learning activity that integrates this new learning into their daily work
Evaluation Methods Focus group discussions 1. Case management concepts 2. Current practice in case management 3. Any practical changes after the educational intervention Self-reported questionnaires: 1. Knowledge regarding case management 2. Performance confidence in case management skills 3. The frequency of using case management skills 4. Preparedness for case manager role activities 5. The frequency of using case manager role activities
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Given that the process of case management is the core function of the case
manager, the six steps of the process formed the foundations of the course content
framework to prepare the PHNs for case management. The content framework
based on these steps formed the course content and is shown in detail in Table 6.2.
Table 6.2
Initial course content framework of the CCMCPE program Steps of CM
process Essential Knowledge Areas Essential Skills Case Manager Role Activities
Case identification and selection
1. Performing case identification, selection, and outreach functions (Case identification)
Assessment and needs identification
2. Identification of actual and potential problems (Assessing)
3. Synthesising assessment information to prioritise care needs and develop treatment plans (Needs identification)
Planning and resource identification
4. Development of the plan of care (Planning)
Service implementation and coordination
5. Communicating with patients, family and revising treatment plans as needed (Negotiating)
6. Implementation of care and treatment plans (Problem solving)
7. Providing education, information, direction, and support related to care goals of patients (Education)
8. Acting as an advocate for the patient and family with service providers (Advocating)
9. Coordinating acquisition of medical equipment (Collaborating)
10. Performing advocacy and intervention functions (Advocating)
11. Preparing transitional planning and referrals
(Problem solving)
Monitoring service delivery
12. Monitoring and evaluating patient’s responses to treatment and revising treatment plans as needed (Monitoring)
Evaluation of patient care outcomes
1. Case management concepts (definition, history, purposes) 2. Case management models 3. Case management process 4. Case management tools; (clinical paths; guidelines) 5. Community resources 6. Specific case management
practice (mentally ill patients)
Case management skills 1. Client assessment 2. Case management
planning 3. Client referral to
resources 4. Implementation of
plan 5. Monitoring of services
and client progress 6. Evaluation of client
outcomes Communication Skills 1. Developing
partnership skills 2. Interviewing skills Leadership skills 1. Advocacy 2. Negotiation 3. Collaboration 4. Critical thinking 5. Problem solving
13. Ongoing assessment, reassessment and follow-up (Evaluating
14. Performing case recording, documentation, report writing functions (Evaluating)
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The course was offered in each health centre, at a convenient time, and by the
academic faculty member. The class size for the program was small, approximately
10 to 24 nurses on each half-day workshop every two weeks, which offered
important time between sessions for nurses to action and change their practice.
Sixteen hours of nurse work time, as identified in the literature, was applied over
four half-day sessions, which was suggested by the head nurses to enable all nurses
allowed to attend. Hence, the workshops lasted throughout 8 weeks.
In order to reach the expected objectives and ensure the greatest benefit from
the program, critical reflection and action plans drawn from transformative learning
were selected to improve translation from classroom to real practice. A combination
of several strategies identified from the literature regarded as effective and
interesting methods were also implemented to address the PHNs’ learning preference
and achieve the expected objectives: these included games, interactive lectures and
group discussions. Four main activities formed the course delivery strategies of this
educational program across four sessions. Table 6.3 describes the learning strategies,
including what these strategies were and how they were applied.
The first type of activity was the induction activity, which motivates learners
and connects learners with what they already know and with their unique context.
Many strategies can be used to ‘warm-up’ the learners, including a story, case study,
history and context, ideal model or example, demonstration, discussion, role-play,
printed literature (newspapers, magazines, posters, manuals), or games. This current
program used games to fit the public health nurses’ preference for interesting
learning methods to motivate the learners to continue to attend the program.
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Table 6.3
Learning strategies of the CCMCPE program
Learning Transitions (Learning Goals)
Strategies Induction (Explore Experience)
Input (Knowledge and Skills)
Implementation -Critical Reflection (Application in Class)
Integration (Action in Workplace)
Assess need • Assess range of experience
• Assess current gaps and needs
• Assess essential knowledge and skills
• Assess resources and strategies
• Assess nurse case manager role activities
Design • Using games to warm up learners
• Using a small group collaboration to motivate them and explore their current knowledge
• Using interactive lectures to update knowledge and skills
• Using visual or audio aids, written handouts or documents, discussion, practical experience, quiz, reading or activity report
• Using critical reflection as learning strategies to reflect current practice
• Using guided small group activities, explanation, practice, role-plays, practical experience, simulation, and demonstration
• Using action plans as learning strategies to achieve transfer practice
• Using written action planning, new practical experience and self-checklist
Deliver • Establish collaborative relationships
• Academic faculty act as a learning facilitator to design tasks, material and to facilitate and enforce their learning
• Public health nurses as learners to collaborate with team members to identify, discuss, reflect, evaluate on given activities
• Using short interactive lectures, reading, case study, products as input learning strategies to integrate and reorganise their transition in knowledge and skills
• Using critical reflection in their current practice to identify, compare, analyse and integrate learned knowledge and skills in given activities through a small group as practical learning activities
• Facilitator and learners work together on learning activities to integrate using action planning and checklists
Evaluation • Monitoring changing requirements and provide further learning strategies
• Maintain and develop learning resources
• Monitoring changing requirements and provide further learning strategies
• Maintain and develop learning resources
• Self-checklists • Group evaluation
• Focus group discussions
• Post tests of knowledge, skills and role activities
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Following the above delivery strategy, the input activity which aimed to
update learners’ knowledge and skills, invited learners to examine new input
(concepts and skills) – the content of this program – using interactive lectures, visual
or audio aids, written handouts or documents, discussion, practical experience,
quizzes, and reading.
The third delivery strategy involved implementation of critical reflection
through collaboration. Critical reflection activities ask learners to reflect on their
current practice according to new content. In this program these activities
incorporated small group guided discussions, practical experience-sharing,
brainstorming, and a debate together. These were collaborative processes between
the facilitator and the participants, and among the public health nurses. Critical
reflection can be seen as one of the core activities guided by transformative learning
theory, because each participant was asked to collaborate with group members to
discuss issues according to given activity directions (See Appendix 3) about current
practical problems and difficulties in their case management practical work. The
researcher then guided brainstorming discussions for possible solutions based on
case management theory.
The last delivery strategy involved an integrative activity which aimed to
integrate new learning from the program into participants’ daily practical work by
using action plans. In order to apply the learned case management knowledge to their
work, all participants were given a task that involved them composing action plans
relating to learned skills or activities in their daily case management work. The
content included the names of possible cases, the planned times and activities during
the next two weeks.
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Two forms of data were used to evaluate the effectiveness of this program,
namely focus group discussions conducted by the researcher and self-report
questionnaires administered by a research assistant. These focused on knowledge
regarding case management, performance confidence in case management skills,
preparedness for case manager role activities, and the self-reported frequency of
using case management skills, and case manager role activities. Each evaluation
measure is described in detail later in this chapter.
In order to provide structure for the program delivery and standardise the
delivery procedures, a training manual and materials were developed by the
researcher to guide the delivery procedures. The researcher developed a training
manual comprising the learning plans (presented in Table 6.4) of the four sessions.
The first session covered case management concepts, including the definition, history,
purposes and models of case management. The case management process consists of
six steps, and related skills and role activities were included in the second and third
sessions. Specific case management practice formed the last session. The manual
included the program plans, course timetable, activity materials for the four sessions,
and the directions for all the activities in the program (See Appendix 3).
In order to confirm the potential effectiveness of the educational intervention
and refine the delivery procedures before conducting the program, an expert panel
review and pilot testing of improvements of the program were conducted.
6.2 EXPERT PANEL REVIEW
Once the initial CCMCPE program had been developed and organised into a
draft training manual, the expert panel reviewed the program using an evaluation
sheet developed by the researcher focusing on content, goals and objectives, program
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design and general evaluation (Lasley, Matczynski & Rowley, 2002) (Appendix 4.1).
These experts assessed the design of the program and wrote down their comments or
suggestions. In addition to reviewing the course design, the same panel members
were asked to rate and review the content validity of each instrument item to be used
in this study. The investigator then reviewed the feedback and incorporated this into
the final CCMCPE program.
Table 6.4
Initial learning plans for the CCMCPE program over four sessions
Session Course Content Learning Activities Time Frame
Session One (Week One)
Case management concepts 1. Definition of case management 2. Historical perspective on case
management 3. Purposes of case management 4. Case management models
1. Pre-tests 2. Induction activities 3. Input activities 4. Reflection activities 5. Integration and action
activities 6. Evaluation
0.5 hour 0.5 hour 1.0 Hour 1.0 hour 0.5 hour 0.5 hour
Session Two (Week Three)
Case management process and skills: 1. Case selection, skills and role
activities 2. Client assessment, skills and role
activities 3. Case management planning,
skills and role activities 4. Interviewing skills 5. Developing partnership skills
1. Induction activities 2. Input activities 3. Reflection activities 4. Integration and action
activities 5. Evaluation
1 hour 1 hour 1 hour 0.5 hour 0.5 hour
Session Three (Week Five)
Case management process and skills: 1. Implementation, skills and role
activities 2. Monitoring service delivery,
skills and role activities 3. Evaluation, skills and role
activities 4. Coordination skills 5. Negotiation skills
1. Induction activities 2. Input activities 3. Reflection activities 4. Integration and action
activities 5. Evaluation
1 hour 1 hour 1 hour 0.5 hour 0.5 hour
Session Four (Week Seven)
Specific case management practices: 1. Care needs of specific
populations 2. Case management tools 3. Community resources 4. Service referrals 5. Advocacy skills 6. Collaboration skills
1. Pre-tests 2. Induction activities 3. Input activities 4. Reflection activities 5. Integration and action
activities 6. Post tests
0.5 hour 1 hour 1 hour 0.5 hour 0.5 hour 0.5 hour
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The panel of experts comprised six individuals familiar with community
nursing case management practices and case management education. The panel
included two current teachers of case management from the social work field (one
associate professor and one professor); two educators with over ten years’ experience
in nursing education (both associate professors holding PhDs in nursing education);
and two experts in community case management practice with over 20 years’
experience in public health nursing.
Initial contact with each potential expert panel member was made by
telephone, describing the study, the requirements for participation and the time line
required for written input. Once the panel members were confirmed, the course
description draft was mailed, along with a covering letter with specific instructions
(Appendix 4.2) and an evaluation sheet (Appendix 4.1) designed by the researcher.
The timeline for the review was two weeks.
All six panel members addressed four main items. The first three were
specific questions, namely ‘Is the course content needed for public health nurses?’,
‘Are the goals and objectives clear and defined?’, ‘Can the course design achieve the
expected goals and objectives?’. The panel members were asked to rate the course
description draft according to these questions on a self-report Likert-type scale.
Three points represented the degree of agreement; a rating of one indicated
disagreement, two was partial agreement and three reflected total agreement. At the
end of each question, an open area was provided for any additional written comments
that the panel member wished to include. The fourth item was a section for general
evaluation of the course draft.
Mean scores for each item were calculated based on the data from the six
expert panel members. Before the analysis took place it was decided by the
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researcher any item that was ranked with a mean score below 2 (from disagreement
to partial agreement) was to be redesigned and reorganised. However, there were no
items in this category. The mean scores of the three items ranged from 2.5 to 2.7,
which meant that all were ranked on average between ‘partial agreement’ and ‘total
agreement’. In general, the expert panel members agreed the designed case
management course content conformed to public health nurses’ needs. Several
experts praised its innovation and diversity. The results provided preliminary
evidence that the program was appropriate for addressing the case management
education gap for PHNs and suggested the program could achieve the expected goals
and objectives.
The researcher also addressed the additional written concerns and suggestions
from the expert panel members. One expert noted the PHNs participating may
already have some knowledge and skills of the proposed course content regarding
case management, and suggested connecting these gaps was a means of addressing
the problem. One member stressed the importance of evaluating the effect of case
management. Another recommended including case management background and
rationale. One interesting comment by a practice-focused expert in case management
emphasised the urgent need for community case management practical knowledge of
mentally ill patients, due to a lack of educational opportunities for PHNs. Although
PHNs also engage in community case management for older adults, it may not be as
necessary to focus on this segment of the community in the current educational
program because most PHNs are experienced with this population and have attended
education programs in this area. One expert also had concerns regarding the course
design, specifically that there may be too many activities to be carried out within the
time frame of the program.
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Subsequently the researcher revised the course plan in response to panel
members’ feedback. Three main changes emerged after the panel review. Firstly,
according to the experts’ suggestions, the topics of case management background
and rationale, evaluation of case management outcomes, and community case
management for mentally ill patients were added into the program. Secondly,
specific terms used in the draft were refined as suggested by the experts. Finally,
strategies to explore public health nurses’ current understanding of case management
were included at the beginning of the program delivery through pre-tests and
inductive activities in each session. The learning activities were reorganised and
rechecked and the time frame was carefully considered and revised to avoid
overcrowding of the activities.
6.3 THE INSTRUMENTS: PSYCHOMETRIC DATA
In order to assess PHNs’ feedback and refine the delivery procedures, a pilot
test was conducted. The pilot test included assessments of both the education
program itself and the testing evaluation instruments used in this main study. After
first establishing the psychometric properties of the instruments, pilot testing of the
designed educational program was implemented in an attempt to improve delivery
procedures and predict possible difficulties.
In order to examine the psychometric properties of the measures used in this
study, the use of content validity index was generated using an expert panel, and a
two-phase (Time 1 and Time 2 measures) design was used to obtain reliability data.
A four-part questionnaire was used to examine three main outcomes of the
educational program. Section One of the questionnaire assessed case management
knowledge Section Two examined case management skills, and Section Three
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assessed case manager role activities. The last section gathered demographic data
about the participants. The variables and measures collected are presented in Table
6.5, accompanied by a detailed description of each measure.
Table 6.5
Variables and measures
Variables Measures Section One: Knowledge Case management knowledge Case Management Knowledge Index with multiple-choice
questions modified from “A Case Manager’s Study Guide Preparing For Certification” (Fattorusso & Quinn, 2004)
Section Two: Skills Performance confidence in case management skills Frequency of use of case management skills
The Practice Skills Inventory (PSI)-Case Management Skills (O’Hare, Collins & Walsh, 1998) with additional items related to communication skills developed by the researcher.
Section Three: Practice Preparedness level in case manager role activities Frequency of use of case manager role activities
Case Management Activity Scale (Anderson-Loftin, 1996)
Section Four: Demographic data For the pre-test Age, highest educational level, years in nursing, years in public health nursing, and prior case management training
Designed for use in this research
Section Four: Evaluation Sheet For the post-test Satisfactory with the program, the usefulness and necessity of the program
Designed for use in this research
6.3.1 Measures
A questionnaire with four sections was the measure used in this study.
6.3.1.1 Section One – Case Management Knowledge
Section One of the questionnaire was the Case Management Knowledge
Index, comprising questions addressing the basic concepts and processes of case
management. The multiple-choice items were modified from “A Case Manager’s
Study Guide Preparing For Certification” (Fattorusso & Quinn, 2004) – a set of
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published case management test materials. Permission was obtained from the
publishers (see Appendix 5.1).
Section One of the questionnaire assessed participants’ knowledge about case
management using The Case Management Knowledge Index. This test explores the
participant’s knowledge of the case management process (encompassing case
identification, needs assessment, resource identification, coordination and referrals,
monitoring, and evaluation) and the basic concepts of case management practice. The
20 multiple-choice questions were obtained (although some were modified) from “A
Case Manager’s Study Guide For Preparing For Certification” (Fattorusso & Quinn,
2004).
Multiple-choice tests are one of the most common forms of cognitive
measures because they are both objective and reliable. A multiple-choice format also
allows for broad content coverage (Fattorusso & Quinn, 2004) and can measure all
types of knowledge. Several authors had previously designed multiple choice
questions to measure knowledge from case management education programs
(Donoghue et al., 2004; Matrone, 1990; Vinton, 1993) but none of these existing
tests focused on the foundational knowledge of the case management process and
related concepts. For example, Matrone’s tool focused on hospital-based case
management in acute care settings, while Vinton’s tool addressed elder abuse and
neglect. Hence, no well-developed instrument was found in the literature that
measured general case management knowledge.
However, many certificated programs in the United States, such as the
Commission for Certified Case Managers (Commission for Case Manager
Certification, 2001), use multiple choice questions to measure essential knowledge of
case management. Such assessments are easy to use to measure foundation
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knowledge with standard validity and reliability. These multiple-choice questions
have been published for Certified Case Managers, such as “A Case Manager’s Study
Guide Preparing For Certification” which has well-established reliability and validity
to measure essential case management knowledge (Fattorusso & Quinn, 2004). Test
items are designed by experts to differentiate between individuals with varying levels
of content knowledge. Hence, 20 multiple-choice items were selected from this
resource and some of them were modified according to the feedback from an expert
panel review to measure understanding of basic concepts and processes of case
management in this study. A comparison between the original and modified versions
of the questions is presented in Appendix 6.1.
The Case Manger’s Study Guide comprises the item pool of the case manager
certification exam and is composed of questions consistent with empirical findings
regarding the knowledge and skills considered important in the delivery of case
management, as identified through a national survey (Fattorusso & Quinn, 2004).
There are six knowledge domains included in the materials. Only questions in the
domain of processes and relationships were included in the current questionnaire.
The related questions about the basic concepts (what, why, where, how, and who)
and the process of case management described in Chapter Two were selected and
formed the main content of the knowledge scale in this study. These selected
questions were further reviewed by the expert panel and examined in the following
pilot testing.
6.3.1.2 Section Two – Case Management Skills
Section Two assessed PHNs’ performance confidence in case management
skills and explored participants’ frequency of using these skills. These items were
drawn from the Practice Skills Inventory-Case Management Skills developed by
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O’Hare, Collins and Walsh (1998) with the addition of five items developed by the
researcher. Approval was obtained from the developer of the instrument for the
investigator to use and modify as necessary (Appendix 5.2).
Public health nurses’ case management skills were measured using the
Practice Skills Inventory-Case Management Skills Subscale, which included five
items developed by O’Hare, Collins and Walsh (1998). The original scale from these
authors comprises 23 items organised into four subscales (supportive, therapeutic,
case management and insight skills) that measure the frequency of certain practice
skills that social workers employ with their clients in field placement. For each skill
participants are required to respond the frequency that they actually use these skills
in their current practice. A five-point frequency scale is used (5 = very often, 4 =
often, 3 = moderately, 2 = seldom, 1 = never/almost never).
The selected case management skills subscale had satisfactory psychometric
properties, as examined by the original developers. The items were tested by 281
social work practitioners by the original authors. The construct validity of the
original tool was assessed by a common factor analysis, with the finding that four
factors explained 60% of the total item variance. The case management skill subscale
accounted for 9.5% of the variance. Cronbach’s alpha coefficient of internal
consistency of this subscale was assessed and was reported as .81 (O’Hare, Collins &
Walsh, 1998). However, this scale did not include communication skills identified as
essential skills for case managers. An additional six items related to communication
skills, addressing developing partnerships, interviewing clients and their families,
linking resources and collaborating with service providers identified from literature
(Cesta & Tahan, 2004; Smith, 1998), were thus developed by the researcher and
included in the current study.
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The six new items assessed six essential communication skills for case
managers as identified from the literature. These included building relations with
clients and their families, interviews with clients and their families, collaboration and
brokerage. In total there was thus a total of 11 items in the Case Management Skill
Scale, 5 adopted from the case management skills subscale and 6 developed by the
researcher (Appendix 6.2). In addition, each of these items was assessed in two
different ways in order to explore two different facets of each skill. These facets were
the educational effectiveness of each skill in terms of participants’ confidence, and
also the participants’ frequency of use of these skills.
Performance confidence is defined as an affective measure, such that it seeks
to determine interests, values, attitudes and beliefs. It is extremely difficult to
preserve the conceptual differences among these concepts (Waltz, Strickland & Lenz,
2005). However, for the purpose of rendering them measurable, they are all
subsumed under the rubric of acquired behavioural dispositions and defined as
tendencies to respond in a consistent manner to a certain category of stimuli. In the
current study, performance confidence measures refer to the measurement of the
confidence that one has about one’s capability to manage to produce desired effects
by actions (Bandura, 1997). The greater the strength of one’s personal beliefs, the
greater the likelihood of behaviour initiation and maintenance. The purpose of
measuring personal efficacy beliefs is to predict the performance of the behaviour by
a person (Schwarzer, 1992). Thus this study sought to measure performance
confidence as a prediction of participants’ behaviours in terms of case management
skills.
Self-report measures are the most direct approach to the determination of
affect. In this type of measure subjects are asked directly what their confidence is
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regarding a certain skill or behaviour (Waltz, Strickland & Lenz, 2005). In the
current study the participants were asked how confident they felt in achieving the
case management skills in which they currently engage. Items relating to
performance confidence in these skills were rated on a scale from ‘1 = very low’ to ‘5
= very high’, with higher numbers representing a better confidence level in
performing case management skills. An example of an item in this scale is ‘Please
rate your current level of confidence in performing the following: make referrals to
other services ?’.
In contrast, frequency of use of these selected skills is a self-reported
performance measure, as it refers to what the participants actually do. It was treated
as a typical performance measure, which is to say that it measures affective
behaviour and attempts to have respondents describe their behaviour as typically
perceived. Typical performance measures usually ask the subjects for a scaled
response to a set of skills (Waltz, Strickland & Lenz, 2005). In the current study
participants were asked how often they actually use specific case management skills.
Items relating to the case management skills were rated on a 1 to 5 scale from 1 =
never to 5 = very often, with higher numbers representing a higher frequency of using
case management skills. An example of an item in this scale is ‘Please rate how
frequently you actually use the following case management skills in your current
practice: make referrals to other services?’.
6.3.1.3 Section Three – Case Manager Role Activities
Section Three of the questionnaire comprised a tool used to measure PHNs’
case management practice in case manager role activities. This tool was based on
Anderson-Loftin’s Nurse Case Manager Impact Profile Part II ‘Case Management
Activity Scale’ (Anderson-Loftin, 1996). Approval was obtained from the developer
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of the instrument for the investigator to use the instrument and modify it as necessary
(Appendix 5.3).
In Section Three of the questionnaire, PHNs’ practice activities were assessed
using the Nurse Case Manager Impact Profile Part II Case Management Activity
Scale (CMAS) developed by Anderson-Loftin (Anderson-Loftin, 1996). The original
scale composed 39 items organised into four subscales. These subscales measure the
frequency of nurse case manager activities in clinical practice (21 items), teaching (6
items), research (6 items), and system advocacy (6 items) (Anderson-Loftin, 1996).
The selected case management activity scale had satisfactory psychometric
properties as determined by the original developer. The original tool has been
assessed for content validity, and the results revealed that the content validity of the
scale was satisfactory, as evidenced by a CVI (an index of content validity) of 95%
(Anderson-Loftin, 1996). Construct validity was assessed by a common factor
analysis and five factors (individual advocacy, clinical practice, teaching, research,
and system advocacy) explained 47.8% of the total item variance. In addition,
Cronbach’s alpha coefficients of internal consistency of the scale were calculated
as .93 (Anderson-Loftin, 1996).
In the current study 27 of these items related to clinical practice and teaching
were included, because these items were related to case management processes and
represented the case manager role-related activities. The items relevant to research
and system advocacy were omitted because the public health nurses did not engage
in these activities in their case management practice work. In order to match the
course content included in the proposed education program – as well as match public
health nurses’ current practice activities – case manager role activities were further
identified and modified. Three items in the original instrument were modified
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because of their focus on hospital-based practice. The comparison between the
original 27 items and the modified items is presented in Appendix 6.3. For the
current study, the initial 27 items were used to measure the effectiveness of the case
management education in their perceived preparedness level and frequency of use of
case manager role activities. Thus the selected case management activity scale was
used to measure two sets of data for the participants.
Preparedness level is defined as an affective measure which seeks to
determine participants’ beliefs (Waltz, Strickland & Lenz, 2005). The purpose of
measuring personal perceived preparedness level was to predict to what extent the
program achieved its goals, given that the key goal of this education program is to
prepare PHNs’ to function in case manager role activities. Participants were thus
asked to report their perceived preparedness level for different case manager role
activities. Items relating to the preparedness level in case manager role activities
were rated on a 1 to 5 scale from ‘very low’ to ‘very high’, with the higher number
representing a better preparedness level for case management practice. An example
of an item in this scale is ‘Please rate your preparedness level for performing the
following activities: coordinate arrangements when referring clients to community
agencies?’.
Again, frequency of use of the case manager role activities is treated as a
performance measure, which refers to what the participants actually do (Waltz,
Strickland & Lenz, 2005). The participants were asked to report their frequency of
use of each of the case manager role activities within their current practice. The
participants were asked how often they achieved the case manager role activities in
which they currently engage. Items relating to the case manager role activities were
rated on a 1 to 5 scale from 1 = never to 5 = very often, with the higher number
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representing a higher frequency of use of case manager role activities. An example of
an item in this scale is ‘Please rate how frequently you actually use the following
activities in your current practice: coordinate arrangements when referring clients to
community agencies’.
6.3.1.4 Section Four – Demographic Data and Evaluation Data
Section Four of the questionnaire included a tool specifically designed to
measure PHNs’ demographic data, including age, highest educational level, years in
nursing practice, years in public health nursing, and prior case management training
and contact hours. For the post-test of the later evaluation study, an evaluation sheet
was additionally designed by the researcher based on Kirkpatrick’s reaction
evaluation to measure PHNs’ satisfaction with the program, and their judgement of
its usefulness and necessity (Kirkpatrick, 2006). This additional information for the
later evaluation study included participant ratings of satisfaction with the program,
and helpfulness and necessity of the program using five-point rating scales from 1
(not at all) to 5 (very) (Appendix 6.4).
6.3.2 Tool Translation
Note that each of the tools used to measure knowledge, skills, and practice
activities were available as English language versions (where taken from previous
sources). These instruments were translated for this study into Chinese in order to
suit the participants. According to Maneesriwongul and Dixon (2004), there is a need
to achieve quality of instrument translation and to report evidence of the accuracy
and validity of instrument translation. Hence, all the English language version tools,
including knowledge, skills and activities, were translated into Chinese versions by
one professional translator and the researcher, and then translated back into English
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by another two professional translators. The two language versions then were
compared to achieve semantic equivalence by two professors of the research team
via electronic mail. One professor suggested replacing some terms (e.g., altering the
‘Medicare plan’ to ‘medical plan’). After revising the translated Chinese instruments,
printed versions of the instruments (accompanied by directions) were tested. The
Chinese version was tested among public health nurses from the two districts in
Taiwan where focus groups had been conducted. Using this method of transcription
means there should be semantic equivalence between the source language version
and target language version (Maneesriwongul & Dixon, 2004). In order to examine
the psychometric data of these instruments, validity and reliability measures were
calculated. The associated procedures and findings are described in the following
section.
6.3.3 Validity Examination of the Instruments
The aspects of validity assessed in this study were content validity and face
validity, achieved through use of an expert panel.
6.3.3.1 Content Validity
Validity means that the individual’s scores from an instrument make logical
sense, are meaningful, and enable the researcher to draw useful and appropriate
conclusions from the sample to the population (Creswell, 2005). Content validity
refers to how well questions or items represent the concept of interest (Creswell,
2005). Steps in developing a content-valid instrument include a development stage
and a judgement-quantification stage. Content validity is frequently estimated from a
review of the literature or through consultation with experts in the field. The
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translated instruments in the current study were tested for content validity using the
same expert panel described in an earlier section.
The use of a Content Validity Index (CVI) is recommended by several
experts and is the most commonly used method of testing the validity of a measure’s
content (Lynn, 1986; Waltz, Strickland & Lenz, 2005). A CVI is defined as the
proportion of items given a rating of quite relevant or very relevant by experts
involved. It is a quantitative method for judging content validity that measures the
proportion or percentage of experts who are in agreement about the relevance of the
instrument (Lynn, 1986; Waltz, Strickland & Lenz, 2005). Content validity can
therefore be assessed by applying the CVI.
The recommended number of experts to review an instrument varies from
two to ten (Gable & Wolf, 1993; Waltz, Strickland & Lenz, 2005). In the current
study the same panel of experts was established as for reviewing the course plans.
The experts were asked to rate the relevance of each item to the objectives in these
questionnaires, using a 4-point rating scale from irrelevant to extremely relevant (4 =
very relevant, 3 = quite relevant, 2 = somewhat relevant, and 1 = not relevant)
(Waltz, Strickland & Lenz, 2005). A rating of one indicated the item content was not
relevant to measure related concepts. A rating of two indicated the item content
needed to be modified, but that it was not absolutely essential. A rating of three
ranked the item content as related but a small component could be revised. A rating
of four indicated item content was appropriate and considered absolutely essential to
measure related concepts. At the end of each question an open area was provided for
any additional written comments that the panel member wished to include. The
content validity inventory developed by the researcher as judged by this method is
shown as Appendix 4.3.
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The three instruments were reviewed, rated and written comments returned
by mail by the required date from the six panel members. Mean scores for each item
were calculated. The results of the CVI indicated the adapted versions of the
knowledge, skill and activity scales had CVIs of 0.87, 0.97 and 0.97 respectively.
These results thus demonstrated adequate content validity.
Prior to receiving the results of the expert panel’s content validity assessment
it was decided the following changes should be made, contingent on the item ratings.
Items receiving a rating of 2 or lower were to be deleted from the instrument. Items
that were given a mean score between 2 and 3 were to be rewritten. Items that
received a collective mean score of 3 or higher (indicating that the panel considered
these items to be appropriate in measuring core concepts) were to be retained in the
instrument for pilot testing.
No items had a mean score below 2, so no item was deleted at this stage. Two
items were given a mean score between 2 and 3. These were rewritten in Part One –
Case Management Knowledge Scale. The experts viewed these items as not related
to current community case management practice. In Part Two – Case Management
Skills Scale and Part Three – Case Manager Role Activities Scale, all the items were
above 3. In summary, all items were kept in the instrument, but two items were
revised.
6.3.3.2 Face Validity
Face validity refers to whether the instrument appears to measure what it
purports to measure (Cottrell & McKenzie, 2005). It pertains to the appearance of an
instrument and includes factors such as clarity, readability and ease of administration.
If an instrument has face validity participants are more apt to be motivated to
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respond (Waltz, Strickland & Lenz, 2005). Thus the expert panel were also asked to
comment on layout, ease of completion and clarity of writing style.
In response to comments by the panel the questionnaire was reviewed and
changes incorporated into the revised instruments as appropriate. Several items were
rewritten based on panel input. In Part One – Case Management Knowledge Index,
Question 1 was altered so that it had a background of community case management
in Taiwan to be more appropriate to the participants. Question 7 was also rewritten
focusing on a community-based setting. Face validity judgements from the
participants were also obtained in the pilot test and will be described in that section.
The revised version of the three instruments contained 58 items. This
included 20 items on the Case Management Knowledge Scale, 11 items on the Case
Management Skills Scale, and 27 items on the Case Manager Role Activities Scale.
However, the items on the Case Management Skills Scale were measured both in
terms of performance confidence and frequency of use. In addition, the items on the
Case Manager Role Activities Scale were measured both in terms of self-reported
preparedness level and the frequency of using these activities. Hence there was a
total of 96 items included in the questionnaire. Once reviewed, revised and modified,
the final draft of the Chinese version was administered to PHNs in a pilot test before
the education program was delivered. The three instruments were piloted utilising
randomised cluster samples in two districts of Taipei City, namely District 1 and
District 2, where the focus groups had been conducted.
6.3.4 Reliability Tests of the Instruments
A pilot test with participants who met the selection criteria was conducted in
order to assess the reliability of the instruments. The aspects of reliability assessed in
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this study were internal consistency and test–retest reliability. In addition, the data
collection procedures were refined through clarification of data collection procedures,
demographic forms, and survey instruments.
This pilot test used a two-phase design, with the first testing occurring at
Time 1 and the second at Time 2. The instruments were pilot tested in both centres
and the initial collaborative case management educational intervention was tested in
one of the centres. The population and sample for the pilot test were chosen using the
same criteria for inclusion and exclusion as the main study described in the section
5.3.1. Public health nurses from District 1 and District 2 health service centres who
engaged in case management practice and who had been public health nurses for at
least six months were invited to take part in the pilot test. These were the same two
districts that took part in the focus groups.
The pilot testing of instruments was carried out on the same day as the focus
group discussions, subsequent to the completion of the discussion session. The
researcher provided each participant with an information package (Appendix 1) and
an instrument inside an envelope. The information sheet explained the purposes,
procedures, time frame and gave completion directions for the instruments
(Appendix 1.4). The investigator then asked those who agreed to participate to
complete written consent forms (Appendix 1.2). After receiving and signing the
consent form, participants were asked to read the directions on the cover page of the
questionnaire. These directions provided details of how to complete the questionnaire
and explained the creation of an ID number. The unique ID number assigned to each
participant was composed of five numbers (first number was the ranking of all
siblings and the last four numbers of their last four ID card numbers). This ID
number allowed the researcher to match the participants’ pre- and post-test
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questionnaires, without sacrificing anonymity. The researcher asked the participants
to attempt all questions even if they were unsure about the answer. The participants
completed the Time 1 questionnaire and returned the questionnaire inside an
envelope to a research assistant.
The researcher asked the participants to note any problems with the questions,
such as poorly worded questions, questions that did not make sense, or whether it
took an excessive amount of time to complete the instruments. The participants were
also invited to ask questions when filling in the instruments. The researcher clarified
any queries immediately. During the data collection period, one nurse indicated that
a question about knowledge regarding case management was unclear. The
investigator explained the question using a different term, which was then
understood by the nurse. A research assistant made notes about the PHNs’ questions
and concerns. The data collection period lasted for half an hour. After two weeks the
same participants were asked to complete the same questionnaire (providing Time 2
data) using identical data collection procedures. The researcher then revised the
instruments based on the feedback.
A demographic section was included in the questionnaire to collect
descriptive information about the sample, including gender, age, and highest degree
in nursing. Information on each nurse’s length of time in nursing, the length of time
as a public health nurse, and prior case management seminars or courses and the
contact hours of these courses was also collected.
Analysis of the data was undertaken using the Statistical Package for the
Social Sciences (SPSS Version 14.0; SPSS Inc, 2005). Accuracy of data entry was
assured by using two separate computerised versions of the data entered by different
persons, and then merged together to verify the differences between all variables.
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Those scores which were not identical were rechecked in the original questionnaires
and revised until there were no differences in the whole data set. This method
ensures that the data entry process is accurate. There were few missing data points
because the participants were asked to provide answers to all questions and the
researcher had asked the participants to check their answers during the data
collection period. Only those responses from participants who completed both Time
1 measurement and Time 2 measurement were retained. Any other incomplete data
was deleted from the database.
A total of 26 nurses participated in the pilot testing, 11 from District 1 and 15
from District 2. A summary of the demographic data is presented in Table 6.6. The
participants were all female, with a mean age of 39 years, ranging from 25 to 52
years old. They had different lengths of experience in nursing (M = 17 years) ranging
from 1 to 30 years, and experience in public health nursing (M = 8 years) ranging
from 1 to 21 years. Over half of the participants had a diploma in nursing. Most
participants (77%) had not attended any training in case management.
Table 6.6
Summary of pilot test participants’ demographic data.
Variables M or Frequency Min Max SD
Participant Numbers 26 PHNs - - -
Age 39 years old 25 52 7.78
Educational Level in Nursing - - -
Vocational high school 4 (15.4%) - - -
Diploma in Nursing 15 (57.7%) - - -
Baccalaureate in Nursing 6 (23.1%) - - -
Master in Nursing 1 ( 3.8%) - - -
Years in Nursing Practice 17 years 1 30 8.58
Years in Public Health Nursing 8 years 1 21 6.94
Prior Case Management Training (Hours)
Yes (23%)
No (77%)
0 50 14.15
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6.3.4.1 Internal Consistency
Reliability means scores from an instrument are stable and consistent
(Creswell, 2005). The reliability of these piloted instruments was established using
tests of internal consistency reliability and test–retest reliability (Waltz, Strickland &
Lenz, 2005). The Cronbach’s Alpha Coefficient or Kuder-Richardson formula 20 (K-
R20) was used to test for internal consistency of instruments (Waltz, Strickland &
Lenz, 2005). The K-R20 is used when the items on an instrument are scored simply
right or wrong (as categorical scores) and the items measure a common factor. The
K-R20 splits the items in half and relates or correlates the items. A higher coefficient
alpha represents higher internal consistency reliability (Creswell, 2005).
The Cronbach’s Alpha Coefficients of the four scale measurements were
from .88 to .96 (Table 6.8). According to Bland (1997), for scales that are used as
research tools to compare groups, α values of .7 to .8 are regarded as satisfactory.
Thus the four instruments used in the pilot test had good internal reliability. The K-
R20 was used to test the internal consistency of the Case Management Knowledge
Index, however, the K-R20 of the Knowledge Index was quite low (.20) which
means item intercorrelations are low. In other words, performance on any one
question is not a good predictor of performance on any other question (Waltz,
Strickland & Lenz, 2005). This is not surprising because these multiple-choice
questions included different concepts of case management selected from the case
manager certification questions according to the content of the proposed program.
In addition, the participants’ knowledge scores were quite low, with a mean
of 9.4 (SD = 2.1), from a possible range of 0 to 20, as presented in Table 6.7.
According to Trevisan’s (1990) study, significant differences exist between K-R20
for low ability students, but no significant differences were found between K-R20 for
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high or average ability students. The knowledge scale of the pilot test included
multiple concepts and all participants were to respond to all questions, even when
they did not know the answers. This is another factor that could reasonably
contribute to the low correlations between the responses. These descriptions suggest
that the K-R20 may not be appropriate as an estimate of reliability in the current
study. The internal consistency of all of the scales was examined again in the main
study, where the sample size was larger. A test–retest reliability procedure was
conducted to ensure the stability of these measurements over a two-week interval.
6.3.4.2 Test–Retest Reliability
The stability of these instruments was determined using test–retest reliability
coefficients. Anastasi and Urbina (1997) noted that, “retest reliability shows the
extent to which scores on a test can be generalised over different occasions; the
higher the reliability, the less susceptible the scores are due to the random daily
changes in the condition of the test takers or the testing environment” (p.92). Test–
retest reliability coefficients indicate the ability of a test to yield similar scores across
repeated measurements. Test score stability is a desirable quality for tests used to
measure student achievement, therefore two-week interval test–retest reliabilities
were conducted.
Table 6.7
Pilot test: Descriptive data for the outcome variables
(1Possible score 0–20, 2 Possible score 1–5).
Variables Time 1 Time 2
Mean Max Min SD Mean Max Min SD
Knowledge1 9.35 14 6 2.10 9.50 13 5 1.60
Skill Confidence2 3.46 4.36 2.45 0.53 3.51 4.82 2.64 0.45
Skill Frequency2 3.49 4.55 2.64 0.51 3.56 5.00 2.82 0.48
Activity Preparedness2 3.17 4.07 2.30 0.50 3.21 4.71 1.96 0.54
Activity Frequency2 3.11 4.04 2.15 0.56 3.26 4.81 2.48 0.52
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A test–retest reliability coefficient (with a two week interval) was computed
for all the measurements in this study, based on the Pearson correlation between the
total or average score from the instruments at Time 1 and at Time 2. Table 6.8
displays the test–retest reliability coefficients. The scales (confidence in case
management skills; frequency of use of case management skills; preparedness in case
manager role activities; and frequency of use of case manager role activities) had
significant test–retest Pearson correlation coefficients ranging from .45 to .82
between Time 1 and Time 2. This indicates satisfactory stability of the five
instruments.
Table 6.8
Test of reliability
Tests Instrument Name
Internal Consistency Cronbach’s Alpha
Test–Retest Pearson correlation
Case Management Knowledge .20# .56*
Confidence in Case Management Skills .89 .53*
Frequency of using Case Management Skills .88 .45*
Preparedness in Case Manager Role Activities .96 .82*
Frequency of using Case Manager Role Activities .96 .77*
* = p < 0.05 # = Kuder-Richardson formula 20 = K-R 20
However, according to Bland and Altman (2003), Pearson correlations cannot
represent the agreement between two measures. These authors therefore suggest
using Bland-Altman plots to determine the limits of agreement. Bland-Altman plots
show all of an individual’s two readings, rather than the mean scores used for the
Pearson correlation. Hence, these plots were created to examine the agreement
between Time 1 and Time 2 measurements.
Test–retest stability was determined by analysing the limits of agreement
(mean difference between the scores of the pre-test and post-test ± 2SDs) and
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presenting them in a Bland-Altman plot. In a Bland-Altman graph, the differences
between the two measurements are plotted against the mean values of both
measurements. The measurements can be considered as reliable if 95% of the
absolute differences lie between the limits of agreement (Bland & Altman, 2003).
The Bland-Altman plot of the total knowledge scores for test–retest (Time 1
and Time 2) agreement is showed in Figure 6.1. The mean difference of total
knowledge scores for test–retest agreement was 0.15 (SD = 1.8) and the limits of
agreement for the mean difference ranged from -3.4 to 3.7 (scores ranging from 0 to
20). The plot showed all participants (26/26) were within the limits of agreement.
Hence, the test–retest agreement of the Knowledge Index used in the current study
was satisfactory.
Figure 6.1
Bland-Altman plot for knowledge scores.
The Bland-Altman plot of the average skill confidence for test–retest (Time1
and Time2) agreement is showed in Figure 6.2. The mean difference in average skill
confidence scores for test–retest agreement was 0.05 (SD = 0.5) and the limits of
agreement for the mean difference ranged from -0.89 to 0.99 (possible scores from 1
to 5). The plot showed that 92% (24/26) of the participants were within the limits of
14.0012.0010.008.006.00
Average of two measurements
4.00
3.00
2.00
1.00
0.00
-1.00
-2.00
-3.00
-4.00
Diffe
renc
e in
read
ings
mean+1.96SD=3.7
mean=0.15
mean-1.96SD=-3.4
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agreement. Hence, the test–retest agreement of the Skill Confidence Scale used in the
current study was satisfactory.
Figure 6.2
Bland-Altman plot for skill confidence.
The Bland-Altman plot of the test–retest (Time 1 and Time 2) agreement for
average skill frequency is depicted in Figure 6.3. The mean difference of average
skill frequency scores for test–retest agreement was 0.07 (SD = 0.5) and the limits of
agreement for the mean difference ranged from -0.91 to 1.05 (possible scores from 1
to 5). The plot showed that 96% (25/26) of the participants were within the limits of
agreement. Hence, the test–retest agreement of the Skill Frequency Scale used in the
current study was satisfactory.
Figure 6.3
Bland-Altman plot for skill frequency.
4.504.003.503.002.50
Average of two measurements
1.50
1.00
0.50
0.00
-0.50
-1.00
Diffe
renc
e in
read
ings
mean-1.96SD=-0.89
mean+1.96SD=0.99
mean=0.05
4.504.003.503.00
Average of two measurements
1.50
1.00
0.50
0.00
-0.50
-1.00
Diffe
renc
e in
read
ings mean+1.96SD=1.05
mean=0.07
mean-1.96SD=--0.91
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The Bland-Altman plot of the test–retest (Time 1 and Time 2) agreement for
average activity preparedness is shown in Figure 6.4. The mean difference in the
average activity preparedness scores for test–retest agreement was 0.05 (SD = 0.3)
and the limits of agreement for the mean difference ranged from -0.56 to 0.66
(possible scores from 1 to 5). The plot showed that 96% (25/26) of the participants
were within the limits of agreement. Hence, the test–retest agreement of the Activity
Preparedness Scale used in the current study was satisfactory.
Figure 6.4
Bland-Altman plot for activity preparedness.
The Bland-Altman plot of the test–retest (Time 1 and Time 2) agreement for
average activity frequency is depicted in Figure 6.5. The mean difference in average
activity preparedness scores for test–retest agreement was 0.14 (SD = 0.4) and the
limits of agreement for the mean difference ranged from -0.64 to 0.92 (possible
scores from 1 to 5). The plot showed that all of the participants were within the limits
of agreement. Hence, the test–retest agreement of the Activity Frequency Scale used
in the current study was satisfactory.
4.504.003.503.002.502.00
Average of two measurements
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
-0.60
Diffe
renc
e in
read
ings
mean+1.96SD=0.66
mean=0.05
mean-1.96SD=-0.56
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Figure 6.5
Bland-Altman plot for activity frequency.
The results revealed that all of the measures had satisfactory agreement
between Time 1 and Time 2, because the plots indicated that 92% to 100% of the
participants in the pilot test were within the limits of agreement. Hence, the test–
retest agreements of the instruments used in the pilot testing were satisfactory.
However, test–retest correlations and limits of agreement of the comparison group,
who had no educational intervention, were to be examined again in the later
evaluation study where the sample size was larger.
6.4 PILOT TESTING THE CCMCPE PROGRAM
After producing the revised educational program, a pilot test with four
sessions (a total of 16 contact hours) was conducted to assess the educational
intervention delivery procedures, estimate the time needed, and consider the
participants’ feedback and suggestions. The public health nurses in one of the piloted
health service centres were invited to attend the education program. Feedback from
participants and the researcher’s own observations during the delivery interaction
were considered in the course of refining the course delivery methods and
readjusting the time frame as required.
4.504.003.503.002.502.00
Average of two measurements
0.90
0.60
0.30
0.00
-0.30
-0.60Diffe
renc
e in
read
ings
mean+1.96SD=0.92
mean=0.14
mean-1.96SD=-0.64
187
The researcher arranged four sessions of four hours’ duration to be conducted,
one of which took place every two weeks. The head nurse sent a notice via e-mail
with the timetable of the proposed program and encouraged the public health nurses
to attend. The first session was executed after the Time 2 instrument testing data
collection. After a brief overview of the program and procedures, the researcher
asked those who were interested in the program to complete consent forms. All of the
12 nurses present signed consent forms, but some indicated that they may need to
leave the sessions to deal with emergency events arising from their duties. The
researcher explained that temporary leave was allowed for their emergency work and
they were welcome to join again when they had finished.
Prior to each session, the researcher prepared printed learning materials and
teaching aids to guide the course delivery procedures. The researcher conducted
induction activities through games to motivate participants’ attention and explore
their current understanding of case management related concepts. During this period
all participants actively joined this activity and helped each other. The researcher
then provided correct answers to each question. Participants enjoyed this activity
very much and stated that they felt it was more efficient learning through interesting
cooperation with other colleagues. Those knowledge gaps identified in these
induction activities were addressed by the facilitator in the following activities.
Following this, the researcher conducted input activities, offering updated
knowledge and foundational case management concepts using a short interactive
lecture. Most of the participants were able to concentrate on listening because these
concepts were relatively new for them. A discussion of any related experiences by
the participants was welcomed during this session. This design allowed the facilitator
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and the participants to establish an interactive atmosphere and a collaborative
relationship.
A number of activities were then undertaken which involved collaborative
exercises between the facilitator and the participants. Critical reflection can be seen
as one of the core activities enabled by transformative learning theory. Each
participant was asked to critically reflect and discuss issues about current practical
problems and difficulties in their case management practical work. A representative,
selected from the team members, wrote the conclusions on the whiteboard. The
researcher then guided brainstorming discussions for the possible solutions based on
case management theory. During these processes public health nurses were able to
critically reflect on their current case management practice and develop possible
strategies to solve any obstacles.
The last kind of activity was an action plan activity. The nurses were asked to
complete a sheet about their action plan after finishing each session. After the action
plan table was finished, the researcher encouraged the participants to implement
these planned activities and write down the problems or questions raised when
carrying out these planned activities in practice. Those who orally presented their
performance or shared experiences with the planned activities received a verbal
reward from the researcher to encourage them to conduct the action plan.
During the pilot testing of the program delivery several issues were identified
by the researcher requiring revision. Firstly, it may be difficult for all the public
health nurses in each health centre to attend the educational programs in each session
because they needed to deal with emergency events, either by telephone or in person.
Some public health nurses also had scheduled regular activities with citizens in the
community which prohibited them attending the sessions. Additionally, the nurses in
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the pilot test needed to finish additional evaluation paperwork during the period the
program was conducted, from October to December. The time to complete such
paperwork might affect their case management daily work. Hence, several strategies
were developed by the researcher to overcome these possible issues prior to the full
implementation of the program.
A simple strategy was implemented by the researcher to allow participants to
leave quietly and inviting them to return once they had finished any emergency
duties. The researcher would then repeat the core content that the individual nurse
had missed. Those who did not attend the course because of scheduled work were
also permitted to attend the same course conducted at another health centre. The
researcher therefore provided a full timetable of all sessions to each coordinator for
reference. In addition, at the beginning of each session, the researcher noted and
emphasised the key concepts to ensure all participants learned at least these aspects
of the session.
Participant’s views of the program were also obtained. The participants stated
they thought the course content was very important for their role as a PHN, and gave
very positive feedback about the community case management practice for mentally
ill patients. After attending the program, they indicated they had obtained fresh ideas
regarding case management and had a clearer understanding about case management
practice. In addition, they felt they knew what activities they could conduct for each
of their cases. The nurses also learned how to assess and identify each case’s needs
and problems when dealing with mentally ill patients. In terms of learning strategies,
they indicated they learned from interesting activities and applied learned knowledge
and skills in their daily work because of greater insight to what activities need to be
undertaken. The comments suggested that the designed course content was
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appropriate and that the learning strategies were interesting and effective for public
health nurses.
After the researcher had reviewed the feedback and observations recorded by
a research assistant, all of the strategies mentioned above were integrated into the
final formal educational intervention delivery procedures. The final delivery
procedures and principles were then elucidated by the researcher in order to
standardise them. When these procedures were clarified and organised, the program
was ready to deliver and evaluate.
6.5 SUMMARY
The CCMCPE program was created through initial development, grounded
on the literature review and an integrative needs assessment, and evaluated by an
expert panel review and pilot test. Each of these procedures was conducted in order
to maximise the potential effectiveness of the program and to identify possible
barriers before program delivery. In addition, all study instruments were tested
during this stage and were found to have satisfactory reliability and validity, except
for the knowledge index. Further reliability tests of the instruments were undertaken
in the main study.
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CHAPTER SEVEN
PHASE THREE: EVALUATION STUDY
Phase Three was comprised of an experimental evaluation study of the case
management education program, which was designed to change public health nurses’
knowledge, skills and practice. The research design, research methods, educational
intervention, and the quantitative and qualitative results are presented in this chapter.
7.1 RESEARCH DESIGN
The review of the literature identified several methodological weaknesses in
previous studies evaluating case management education programs. Several features
were therefore incorporated in the design of the present study to enhance
methodological rigour in addressing the study’s research questions. These features
included:
1. Use of a cluster sampling strategy to randomly allocate participants to comparison
or experimental groups;
2. Use of assessments both before and after the educational intervention;
3. Use of a large sample size;
4. Use of tested measurements with established reliability and validity;
5. Implementation of an educational intervention based on evidence from a literature
review and a needs assessment, and grounded in a theoretical framework suited to
nursing staff;
6. Fostering collaboration between academic and clinical settings;
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7. Use of mixed evaluation methods to assess the effect of the intervention on
knowledge, skills and practice.
These features guided the aims of the research, the selection of the research
questions, the design chosen, and the creation of the educational intervention
program itself. The study used a mixed method approach to data collection. Mixed
methods refer to the use of both qualitative and quantitative data collection and
analysis strategies within a single study (Creswell, Fetters, & Ivankova, 2004;
Teddlie & Taskakkori, 2003). In this study, an evaluation of the intervention program
included quantitative methods to assess the outcomes of the program and qualitative
methods to explore the program’s impact on practice. The quantitative approach used
pre- and post- testing with two groups of participants. The qualitative component
used a focus group discussion to gather data to answer the target research questions.
The research design is presented in Figure 7.1.
Experimental and comparison groups, and a pre-test, post-test design were
used to evaluate the effect of the collaborative case management continuing
professional education (CCMCPE) program. The key aspects the program sought to
address public health nurses’ knowledge about case management, confidence in
performing case management skills, use of case management skills, preparedness for
case manager role activities, and use of case manager role activities. In addition, one
focus group explored the effect of the educational intervention on PHNs’ practice
after the intervention, namely how PHNs’ practice had changed following the
completion of the education program in the experimental groups. This mixed
method approach offered a broader means of evaluating the effect of the education
program.
Phase One Phase Two Phase Three
Figure 7.1
Research design for experimental evaluation study
Time 1 (baseline) Comparison group
Time 1 (baseline) Experimental group
Time 2 (8 weeks later) Comparison group
Time 2 (8 weeks later) Experimental group
Knowledge Skills Role activities CCMCPE program
No education program CCMCPE program
Knowledge Skills Role activities
Knowledge Skills Role activities
Knowledge Skills Role activities
Focus group 8 Nurses
Needs assessm
ent through two focus groups
Pilot testing of instruments in tw
o randomly
selected centres
Pilot testing of the program in one centre
193
194
The four main research questions and sub-questions addressed within Phase
Three were:
• Question 1: Are the PHNs satisfied with the CCMCPE program? (Level I)
• Question 2: Is the CCMCPE program effective in improving PHNs’ learning
outcomes? (Level II)
2.1 Is there a difference in self-reported knowledge about case management
between public health nurses who received the case management continuing
professional education program and those who did not?
2.2 Is there a difference in self-reported performance confidence in case
management skills between public health nurses who received the case
management continuing professional education program and those who did
not?
2.3 Is there a difference in level of self-reported preparedness for case
manager role activities between public health nurses who received the case
management continuing professional education program and those who did
not?
• Question 3: Is the CCMCPE program effective in improving PHNs’
performance outcomes? (Level III)
3.1 Is there a difference in self-reported frequency of using case management
skills between public health nurses who received the case management
continuing professional education program and those who did not?
3.2 Is there a difference in level of self-reported frequency of using case
manager role activities between public health nurses who received the case
management continuing professional education program and those who did
not?
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• Question 4: Are there changes in case management practice for those who
attended the collaborative case management continuing professional education
program? If yes, how has practice changed? If not, what factors hinder
changes?
The study set out to test the following specific research hypotheses:
1. Public health nurses who receive the CCMCPE program will be satisfied with
the CCMCPE (Research Question 1).
2. Public health nurses who receive the CCMCPE program will report higher
levels of knowledge about case management compared to those who do not
receive the program (Research Question 2.1).
3. Public health nurses who receive the CCMCPE program will report higher
performance confidence in case management skills compared to those who do
not receive the program (Research Question 2.2).
4. Public health nurses who receive the CCMCPE program will report a higher
level of preparedness for case manager role activities compared to those who
do not receive the program (Research Question 2.3).
5. Public health nurses who receive the CCMCPE program will report greater use
of case management skills compared to those who do not receive the program
(Research Question 3.1).
6. Public health nurses who receive the CCMCPE program will report greater use
of case manager role activities compared to those who do not receive the
program (Research Question 3.2).
7. Public health nurses who receive the CCMCPE program will report changes in
their case management practice (Research Question 4).
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The main dependent/outcome variables in this study were the subjects’
knowledge about case management, their performance confidence in case
management skills, the frequency of use of case management skills, their level of
preparedness for case manager role activities and the frequency of use of case
manager role activities. All were measured as continuous variables. The independent
variable was thus the educational intervention, the purpose-designed CCMCPE
program.
Potential influencing variables in the current study included organisational
factors and the PHNs’ demographic factors. However, given that the public health
nurses in each district had the same organisational resources and policy evaluation
for continuing education, the assumption was made that the organisational factors
were very similar between the experimental and comparison groups and thus did not
affect the findings. In addition, baseline data was obtained in order to establish group
profiles. This included demographic details (age, educational level, duration of
nursing practice, duration in public health nursing and prior case management
training), knowledge levels, confidence and frequency of use of case management
skills, and preparedness levels and frequency of use of case manager role activities.
These measures enabled an evaluation to be made of the effect of the educational
intervention.
7.2 ETHICAL CONSIDERATIONS
Ethical approval was obtained from the Human and Research Ethics
Committee at Queensland University of Technology (Appendix 7.1), and the
National Taipei College of Nursing (Appendix 7.2). The public health nurses were
provided with detailed information about the study through information sheets, and
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written consent was obtained from each participant. The participants were assured
that there was no risk from participating in the course, and that their responses would
be anonymous and confidential. The PHNs were also assured that the findings of the
study would not impact on their present or future work situations or positions.
The education program required nurses to attend the course over eight weeks,
with four-hour sessions once every two weeks. The participants were told that they
would be required to complete questionnaires, but that this process should take no
more than 20 minutes. All these activities were to be undertaken during work time.
Throughout the study all responses by the participants were recorded
anonymously and treated confidentially. The names of individual persons were not
recorded, as an ID number (described above) was created for them. All information
collected was confidential and was not disclosed in raw form to anyone other than
the researcher. When the results of the study were published, no person or group was
identifiable. The focus groups were tape-recorded but no names were used during the
discussion and only the researcher had access to the tapes. All information was kept
in a locked filing cabinet, and only the researcher had access to the cabinet.
Public health nurses' participation in this project was voluntary. If they agreed
to participate, they could withdraw from participation at any time during the project
without comment or penalty. They were assured that their decision to participate
would in no way impact upon their current or future relationships with QUT or the
National Taipei College of Nursing. Note that the same education program with
training materials and/or complementary training methods (self-learning with
training materials) was provided to the nurses in the comparison group after data
collection was finalised.
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7.3 RESEARCH METHOD
This section describes the research method used in Phase Three, including
details of the setting and sample, measurements taken, data collection procedure,
education intervention and data analysis.
7.3.1 Setting and Sampling
The target population for the research comprised all public health nurses in
the city of Taipei, Taiwan. At the time of testing approximately 205 public health
nurses were employed in 12 administration districts of Taipei City. Each district had
a single health care centre employing 9 to 24 public health nurses. Taipei City was
selected as the location for the study because it was the capital (and largest) city of
Taiwan. It was also the first area in Taiwan to establish a health policy using case
management for individuals with mental illnesses and older adults living alone in the
community. The investigator obtained approval for the research from all 12 health
centres (Appendix 8.1).
A cluster sampling strategy was used in this research. The sampling strategies
used to determine the eligible districts are shown in Figure 7.2. Two health centres
were randomly selected for the pilot testing. The remaining ten health centres were
used in Phase Three and randomly allocated to either the experimental group or the
comparison group. The allocation method used 10 cards containing the name of each
health centre and an invited third party randomly allocated the cards to either the
experimental or comparison group. All registered public health nurses in the ten
centres were potentially eligible to be participants in the Phase Three research study.
All nursing staff in the ten health centres were invited to attend the study.
Five health service centres formed the experimental centres. Numbers were used to
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delineate the districts to ensure anonymity. These were the health centres at Districts
3, 5, 7, 9 and 11, comprising a total of 97 nurses in the experimental group. All
nursing staff in the remaining five health centres formed the comparison group
(Districts 4, 6, 8, 10 and 12), with 78 nurses.
Figure 7.2
Sampling strategies to determine the study sample in Taipei City, Taiwan.
In order to ensure a sufficient number of participants and to motivate their
continuing attendance at the program, the researcher presented the proposed research
to the Health Department of the Taipei City Government, which is responsible for
supervising community health centres. The researcher also visited the head nurses of
each district and sought support from the district managers. All twelve districts
provided approval for their staff to participate in the study. The researcher then
2 Districts randomly selected for pilot study (30 PHNs)
12 Districts in Taipei City (205 PHNs)
10 Districts randomly allocated
87 eligible PHNs
5 Experimental districts for main study
5 Comparison districts for main study
76 eligible PHNs
85 completed study
78 PHNs
97 PHNs
76 completed study
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organised a meeting of all the coordinators of the health care centres (usually these
were head nurses or representative coordinators) to arrange the timetable of the
program, as it would have been difficult to arrange this with each centre separately.
During the coordinators meeting the researcher explained the study, the
course content, time frame and general delivery methods. The term ‘priority course
group’ was used to refer to the experimental district health centres and the term ‘later
course group’ for the comparison district health centres, so as to avoid systematic
bias in the results from this source. Each coordinator was asked to offer their
preferred four half days on an empty timetable sheet. After all coordinators provided
this information, the researcher rechecked any overlapping times and negotiated
changes, and then finalised the scheduled timetable for the educational program in
the ten districts.
Following the meeting, the coordinators gave the invitation letter (Appendix
1.3) and scheduled timetable to all public health nurses in their health centre. They
then organised a list of staff within their centre and passed it to the researcher. The
coordinators also organised one meeting time in which the researcher could explain
the study and course content to the nurses. A total of 175 public health nurses
attended these meetings across the ten health centres.
The public health nurses were fully informed about the research study and
asked to provide written consent for their participation. The researcher explained the
study and collected pre-test data at an arranged time offered by the coordinators at
each health centre. All pre-testing for both the experimental and comparison districts
took place before the first session of the intervention program.
At the arranged times the researcher explained the study to all the PHNs in
each health centre, and passed out information packages (which included the planned
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education topics and the education program details). Once the researcher had spoken
to staff and answered questions, she asked the nurses to read the information sheets
and sign the consent form (Appendix 1.2) if they wish to participate. Those interested
in participating were able to contact the researcher for further information about this
program. The same processes were undertaken at each of the ten participating health
service centres.
The inclusion criteria for participants in this study were the same as reported
earlier for the focus groups (see Chapter Six). In addition, the participants needed to
be available to attend the study for the full eight weeks without any changes in their
employment. In the experimental group, ten nurses in one district did not meet the
criteria because they did not engage in case management work. Two nurses declined
to participate because they were retiring from their jobs. In the comparison group,
two nurses did not meet the criteria as they had not been community health nurses for
six months. In total, 163 eligible PHNs were identified in the ten districts, 161 of
whom agreed to participate.
7.3.2 Measures
Outcome measures were assessed by three instruments (the Case
Management Knowledge Index, Case Management Skills Scale and Case Manager
Role Activities Scale), and a tool designed to measure PHNs’ demographic data.
These were used to measure knowledge about case management, performance
confidence in case management skills, frequency of using case management skills,
level of preparedness for case manager role activities, and frequency of using case
manager role activities. The measures were described in detail in Chapter Six. The
psychometric properties of these measures were established through pilot testing,
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including content validity, face validity, internal consistency reliability and test–
retest reliability (see Chapter Six). The results indicated that the adapted version of
the knowledge, skill and activity scales have satisfactory validity and reliability.
The internal consistency ratings of the instruments were assessed again in the
current evaluation study to take advantage of the larger sample size (161 PHNs in the
two groups completed the pre-test measures). The Cronbach Alpha coefficients of
the measurements ranged from .91 to .96: skill confidence was .91; skill frequency
was .92; activity preparedness and frequency was .96. According to Bland (1997),
for scales that are used as research tools to compare groups, α values of .7 to .8 are
regarded as satisfactory. Thus the instruments used had satisfactory reliability.
Not surprisingly, a low Kuder-Richardson formula 20 (K-R20) of .48 for the
Case Management Knowledge Index was found in the pre-test. This may have been
due to participants’ low scores in the knowledge test. In order to explore this further,
the K-R20 of post-test data was also examined and found to be .78. This is consistent
with Trevisan’s (1990) study which found significant differences between K-R20s
for different performance scores. In the current study a higher mean score of 13.3 (of
20 items) was associated with a higher KR-20 in the post-test, whereas the pre-test
generated a low mean score of 9.8 (20 items) and a lower KR-20. Thus it was
considered appropriate to report both sets of reliability data.
The weak internal consistency data fits with the conceptual belief that the
Knowledge Index used in this study measured general knowledge about case
management, and as such covered several different aspects of case management. The
Knowledge Index thus reflected several different concepts, but there were too few
items to form any meaningful sub-scales. This study therefore first treated the Case
Management Knowledge Index as one general test score. However, when reviewing
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the correlations between each item and the total scale, items 15 and 16 had the lowest
item-total correlations. If these two items were deleted, the K-R20 increased from .48
to .51 in the pre-test, and from .78 to .80 in the post-test. In order to establish better
reliability for the scale as a whole, items 15 and 16 were deleted from the Knowledge
Index. Hence, a total of 18 items were used in the Case Management Knowledge
Index, so that scores for this scale ranged from 0 to 18.
The data suggested that the KR-20 may not be a good indicator of reliability
in the current study. Thus this study further explored the test–retest data of the
comparison group to test the temporal stability of the instruments used in the study.
Pearson correlations of the five measurements were all significant at the α = .001
level, ranging from .46** to .69**. This evidence demonstrates that all the
measurements used in this study had satisfactory stability across the eight week
interval.
Bland-Altman plots were also used to judge the agreements between the pre-
tests and post-tests. Test–retest agreement was determined by analysing the limits of
agreement (mean difference between the scores of the pre-test and post-test ± 2SDs)
and presenting them in a Bland-Altman plot. The Bland-Altman plot of the total
knowledge scores for test–retest agreement is shown in Figure 7.3. The mean
difference in total knowledge scores for test–retest agreement was .01 (SD = 2.2) and
the 95% confidence interval for the mean difference ranged from -4.3 to 4.3 (possible
scores from 0 to 18). Figure 7.3 shows that 95% (72/76) of the participants in the
comparison groups were within two standard deviations of the mean difference.
Hence, the test–retest agreement of the Knowledge Index used in the current study
was satisfactory.
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Figure 7.3
Bland-Altman plot for reproducibility of knowledge scores.
Similarly, the Bland-Altman plot of the test–retest agreement for skill
confidence scores is depicted in Figure 7.4. The mean difference in average skill
confidence scores for test–retest agreement was -0.04 (SD = 0.4) and the 95%
confidence interval for the mean difference ranged from -0.82 to 0.78 (possible
scores from 1 to 5). Figure 7.4 shows that 93% (71/76) of the participants in the
comparison groups were within two standard deviations of the mean. Hence, the
test–retest agreement of the Skill Confidence Scale used in the current study was
satisfactory.
14.0012.0010.008.006.004.00
Average of two measurements
6.00
4.00
2.00
0.00
-2.00
-4.00
-6.00
Diffe
renc
e in
read
ings
mean+1.96 SD=4.3
mean-1.96 SD=-4.3
mean=0.01
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4.002.00
Average of two measurments
1.00
0.50
0.00
-0.50
-1.00
-1.50
-2.00
Diffe
renc
e in
read
ings
mean+1.96SD=0.78
mean-1.96 SD=-0.82
mean= -0.04
Figure 7.4
Bland-Altman plot for reproducibility of skill confidence.
The Bland-Altman plot of the test–retest agreement for skill frequency scores
is shown in Figure 7.5. The mean difference in average skill frequency scores for
test–retest agreement was -0.06 (SD = 0.5) and the 95% confidence interval for the
mean difference ranged from -0.97 to 0.85 (possible scores from 1 to 5). Figure 7.5
shows that 93% (71/76) of the participants in the comparison groups were within two
standard deviations of the mean. Hence, the test–retest agreement of the Skill
Frequency Scale used in the current study was satisfactory.
Figure 7.5
Bland-Altman plot for reproducibility of skill frequency.
5.004.504.003.503.002.502.00
Average of two measurements
1.00
0.00
-1.00
-2.00
Diffe
renc
e in
read
ings
mean+1.96SD=0.85
mean-1.96SD = -0.97
mean = -0.06
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The Bland-Altman plot of the activity preparedness scores for test retest
agreement is shown in Figure 7.6. The mean difference in average activity
preparedness scores for test–retest agreement was -0.01 (SD = 0.4) and the 95%
confidence interval for the mean difference ranged from -0.79 to 0.77 (possible
scores from 1 to 5). Figure 7.6 reveals that 92% (70/76) of the participants in the
comparison groups were within two standard deviations of the mean. Hence, the
test–retest agreement of the Activity Preparedness Scale used in the current study
was satisfactory.
Figure 7.6
Bland-Altman plot for reproducibility of activity preparedness.
The Bland-Altman plot of the activity frequency scores for test retest
agreement is shown in Figure 7.7. The mean difference in average activity frequency
scores for test–retest agreement was 0.02 (SD = 0.5) and the 95% confidence interval
for the mean difference ranged from -0.95 to 0.99 (possible scores from 1 to 5).
Figure 7.7 reveals that 95% (72/76) of the participants in the comparison groups
were within two standard deviations of the mean. Hence, the test–retest agreement of
the Activity Frequency Scale used in the current study was satisfactory.
4.504.003.503.002.50
Average of two measurements
1.00
0.50
0.00
-0.50
-1.00
-1.50
-2.00
Diff
eren
ce in
read
ings
mean+1.96SD = 0.77
mean-1.96SD = -0.79
mean = -0.01
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Figure 7.7
Bland-Altman plot for reproducibility of activity frequency.
The results of these analyses thus revealed that all instruments had
satisfactory agreement between two measurements, because these plots showed 92%
to 95% of the participants were within the limits of agreement. Hence, the test–retest
agreements of the instruments used in the current study were satisfactory. A
summary of the instruments’ psychometric qualities is presented in Table 7.1.
7.3.3 Procedures for Data Collection
7.3.3.1 Quantitative Data Collection
Prior to completing the questionnaires (see Appendix 9.1), the PHNs were
fully informed and had signed consent forms. The researcher then told the nursing
staff that they were allocated either to the priority course group or the later course
group. The researcher did not mention the terms ‘experimental’ or ‘comparison’ in
order to avoid systematic bias. However, some participants with research training
might still have known that they had been allocated to an experimental or
comparison group. Thus this study could not be a blind experiment. The PHNs from
the five experimental districts received the educational program first. For ethical
4.003.503.002.50
Average of two measurements
2.00
1.00
0.00
-1.00
-2.00
Diff
eren
ce in
rea
ding
s
mean+1.96SD = 0.99
mean-1.96 SD = -0.95
mean = 0.02
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reasons the comparison districts received the same educational program after
completing all of the post-tests.
Table 7.1
Summary of instrument quality
Concept Instrument Reliability Validity
Knowledge Case Management Knowledge Index
Internal consistency reliability (KR-20) of .50 in the pre-test and .80 in the post-test Test–retest of .63** significant Pearson correlation for the comparison group Test–retest agreement 95% for the comparison group in the main study
Content validity through CVI (Content Validity Index) with .87; and face validity in the pilot study
Skills Case Management Skills Scale -confidence -frequency
Original test: Cronbach’s alpha coefficient was .81 in case management skills subscale (O’Hare, Collins & Walsh, 1998) Internal consistency reliability with Cronbach Alpha coefficient .91 of skill confidence; .92 of skill frequency in the main study Test–retest with significant Pearson correlation .66** skill confidence; .69** skill frequency for the comparison group Test–retest agreement 93% for the two scales of the comparison group in the main study
Original construct Validity was assessed by common factor analysis and explained 60% variance; case management skills subscale accounted for 9.5% Content validity through CVI (Content Validity Index) with .97; and face validity in the pilot study
Practice Case Manager Role Activities Scale -preparedness -frequency
Original test: Cronbach’s alpha coefficients were .93 (Anderson-Loftin, 1996). Internal consistency reliability with Cronbach Alpha coefficient 0.96 of activity preparedness for activity and activity frequency in the main study Test–retest with significant Pearson correlation of .58** for activity preparedness; .46** for activity frequency in the comparison groupTest–retest agreement 92% for activity preparedness; 95% for activity frequency using the comparison group in the main study
Original CVI (An index of content validity) was 95% (Anderson-Loftin, 1996) Construct Validity was assessed by common factor analysis and five factors explained 47.8% variance Content validity through CVI (Content Validity Index) with .97; and face validity in the pilot study
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In order to prevent contamination between experimental and comparison
districts and to offer the participants a convenient option, the program was held
separately in each district. Minimal staff interaction occurred between districts
because all public health nurses work in their own centre and district areas, and
average distances between each district in Taipei City range from 20 minutes to one-
hour driving time. It is not usual for PHNs from one centre to have contact with
PHNs at other centres.
The questionnaires in Chinese (Appendix 9.2) were distributed before the
educational program had commenced, and again eight weeks after the educational
program was completed. Each of the four sessions was held every two weeks and
thus the program lasted for a total of eight weeks. This allowed time for the
participants to change their practice and allowed the researcher time to conduct the
program in the five experimental districts, with two or three courses held in a single
week. In the experimental groups, the self-report questionnaire was completed in the
classrooms on the first and last program session. The data collection procedures were
similar to the pilot testing of the instruments. The questionnaires included a covering
letter explaining how to complete the instrument, and how to generate a unique ID
number. This unique number was used to match each participant’s pre- and post-test
responses. The researcher explained to participants that the Time 1 measures offered
valuable data relating to their current case management practice, and asked the
participants to give full answers to all questions. Nurses were also asked to recheck
their answers. The participants returned the questionnaires inside the original
envelope to the investigator immediately after completion. The same data collection
procedures were conducted in the last session eight weeks later.
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The pre-test data was collected from the comparison groups using the same
procedure, and during the same period as the experimental districts. After receiving
the PHNs’ approval, the investigator collected questionnaires at arranged times to
increase the rate of return. For those who were not able to attend these Time 1
assessments at the arranged time, the coordinator passed them questionnaires in
envelopes which were to be mailed to the investigator via a stamped addressed
envelope. Time 2 testing was completed in the first education program session held
for the comparison groups, which was after the educational intervention finished for
the experimental groups. Time 2 measurements were conducted eight weeks after the
Time 1 measurements because the program lasted for eight weeks.
7.3.3.2 Qualitative Data Collection
The qualitative data was gathered from a single focus group discussion held
with a subset of participants from the experimental group. The key purpose of the
focus group, held after the educational intervention, was to explore the impact of the
program on public health nurses’ case management concepts, and to ascertain
whether their case management practices had changed and if so, the factors that had
influenced those changes. The main three areas for discussion were current case
management concepts, how practice had been changed, and if practice had not been
changed, what factors hindered changes?
The researcher moderated the focus group. At least two nurses from each
experimental health service centre were invited to the focus group, but others who
were interested in the focus group were also welcome to attend. The standardised
data collection procedures used for the earlier focus group discussions (described in
Chapter Six) were used to collect data in this study. A Focus Group Discussion
Guide was also developed and is presented in Appendix 2.2. Several semi-structured
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questions identified from the literature review were designed to guide the focus
group discussion. These included questions such as, ‘have case management
practices changed since the education program?’, and ‘how have the case
management practices changed?’. A tape recorder was used to record the discussions.
This recording was then transcribed and kept as a complete record of the discussion.
This information facilitated analysis of the data.
7.3.4 Data Management and Analysis
Analysis of the quantitative data was undertaken using the Statistical Package
for the Social Sciences (SPSS Version 14.0; SPSS Inc, 2005). Accuracy of data entry
was ensured using the same methods as described for the pilot test. Two separate
computerised versions of the data entered by different persons were merged together
to verify the differences between all variables. Those which did not show ‘zero’ were
rechecked in the original questionnaires and revised until there were no differences
in the data set. There were few missing data points because the participants were
specifically asked to provide full answers and to recheck their answers during the
data collection period. All the participants completed both the Time 1 and Time 2
measurements. Before each statistical test was conducted, the underlying
assumptions for the tests were examined. Statistical significance was reported at an
alpha level of .05. All t-tests were two-tailed in nature. Statistical tests were then
undertaken as described below, including both descriptive and inferential statistical
methods.
Descriptive statistics were used to examine the demographic variables,
baseline variables, and outcome variables for both groups to ensure comparability of
the experimental and comparison groups. The mean and standard deviation was
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calculated for all continuous variables, including age, years of nursing practice, and
years in public health nursing. Percentages for dichotomous or categorical variables
were also calculated, including gender, prior case management training and highest
educational level in nursing. Outcome variables included case management
knowledge, confidence in performing case management skills, frequency of use of
case management skills, level of preparedness for case manager role activities, and
frequency of use of case manager role activities. Any differences detected were
controlled for during subsequent analyses.
Inferential tests were used to examine baseline differences between the
experimental and comparison group before the intervention on continuous
demographic variables (age, years in nursing and years in public health nursing) and
the outcome variables (case management knowledge, performance confidence in
case management skills, frequency of use of case management skills, preparedness
level in case manager role activities, and performance frequency of use of case
manager role activities). Two sample t-tests were performed on the outcome
variables that were composed of interval data in order to compare means of the
experimental and comparison groups. When the underlying assumptions were not
met, a Mann-Whitney test was performed.
The underlying assumptions of each test were examined before the tests were
conducted. Normality of distribution and homogeneity of variance are the
assumptions of most of the inferential tests (t tests and ANOVAs) used in the study.
The distribution of variables was assessed by histograms and measures of mean,
median, standard deviation (SD), skewness and kurtosis, as both graphical and
numerical methods are best to provide objective information on the normality of
variables (Henderson, 2006; Osborn, 2006). A normal distribution can be visually
213
determined using a histogram, as it should be bell-shaped and symmetrical (Meyers,
Gamst, & Guarino, 2006). Several indicators suggest when a distribution may not
differ significantly from normality. These include when the obtained mean and
median ± 10%, when the SD is not over 1/3 of the mean, and when skewness and
kurtosis values are ± 1 (George & Makllery, 2003; Osborn, 2006). All these
techniques were used to determine the data distribution of variables in this study. The
results are presented according to the criteria described as above.
The inferential statistical tests for the five research questions consisted of
two-way repeated measures ANOVAs. Two-way repeated measures ANOVAs were
used to evaluate the differences in outcome variables, with independent variables
being Group (intervention verses comparison), Time (pre-test versus post-test), and
the interaction between Group and Time. Inferential statistical tests were then used to
detect baseline differences pre-test (before the intervention) between the
experimental and comparison groups for the continuous demographic variables and
the five outcome variables.
In contrast, a qualitative content analysis was undertaken on the qualitative
data obtained from the focus group. The same data analysis procedures (the 14 stages
of content analysis described by Burnard, 1991) undertaken in the needs assessment
described in Chapter Six were used. The complete transcriptions were used to
analyse the content of the discussion. The aim of the analysis was to look for trends
and patterns amongst the data. Grouped according to the target question, categories
and subcategories were identified. Following the results of the qualitative content
analysis, the researcher developed a statement regarding the collected data.
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7.3.5 Intervention
The CCMCPE was an educational intervention consisting of four half-day
sessions conducted every two weeks in the five experimental health centre districts.
There was thus a total of 16 hours of workshops, and the program lasted for a total of
eight weeks. The course content was focused on the case management process and
related activities, with an aim to improving public health nurses’ knowledge, skills
and practice in case management and their ability to function in case manager roles.
The researcher acted as a learning facilitator and collaborated with the public health
nurses to improve their case management practice. Public health nurses were also
involved and collaborated with their group members in the designed activities,
especially using reflection on their prior work experience and current practice
through guided group discussions. The four main learning activities were designed to
achieve the expected multiple levels of outcomes, including satisfaction, learning and
performance levels. The program delivery processes in the four sessions followed the
procedures developed by the researcher after pilot testing and were presented
according to the learning plan, as detailed in Chapter Six.
The public health nurses in the experimental group were encouraged to attend
this program through their directors, their head nurses and the health department of
Taipei City Government. The program was held in each health service centre at times
suggested by the coordinator of each centre in order that the public health nurses
could easily access the programs. In coordination with public health nurses’ working
hours, the facilitator conducted the same topic several times at the health centres and
supplied the teaching plan in advance. In addition, the researcher allowed
participants to leave quietly and invited them to return once they had finished any
emergency duties. The researcher also described the key concepts at the beginning of
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each session. In these ways, the public health nurses had many choices of times to
attend, depending on their availability, and nurses who missed some parts of the
program could easily catch up.
The education program was held in a quiet teaching room within each centre.
All participants received a learning package comprising a pen, notebook, training
manual designed by the researcher, a feedback sheet, and a bag. The program was
composed of four main activities as learning strategies to guide the program delivery
processes of the four sessions. These four learning activities continued throughout
the four different sessions. These procedures are described in detail below.
Induction activities were designed to motivate the learners and explore their
current understanding of case management and related concepts. At the beginning of
each session a game was undertaken in order to explore participants’ current level of
knowledge and to motivate them to learn. In this activity the facilitator/researcher
first asked participants to form a small group of three to four members. The
facilitator then offered a package of questions (or activities) related to each of the
course sessions (the basic concepts of case management and case management
process related role activities) and answer cards. The group members needed to
follow the learning directions and cooperate with other members (find the correct
answer to each question or classify the role activities) until all the questions and
classifications were completed. The facilitator then checked their answers and
pointed out any wrong answers. In this way the facilitator is able to understand the
knowledge gaps of the participants and encourage the learners to find the answers in
the following interactive lecture. The induction activities lased for 30 minutes.
Following the games, the input activity invited learners to examine new
information (knowledge and skills, the content of the program), and practical
216
experience sharing. The facilitator provided input regarding key concepts of case
management and encouraged the learners to share their related experience. This
aspect of the program was designed to fit the participants’ learning preference.
Interactive sessions using lectures, visual aids and written handouts together with
case examples, a story, demonstration and role-plays were used to interpret and
update the participants’ knowledge and skills of case management. After the
presentation, the participants were asked to check their answers again and discuss
with other group members to clarify the concepts they had learned. This process
allowed the facilitator and the participants to establish an interactive atmosphere and
a collaborative relationship. The interactive lecture lasted one hour.
The third type of delivery strategy involved implementation activities -
critical reflection. These were collaborative processes between the facilitator and the
participants and among the participants, which allowed the nurses to critically reflect
on their current case management practice in the designed activities. Critical
reflection activities were undertaken in small groups using guided discussions,
practical experience-sharing, brainstorming, and a debate. The guided discussions
were undertaken on specific topics related to case management practice for older
adults living alone and mentally-ill patients. Practical issues and topics discussed
were designed by the researcher for each group to critically reflect upon. A
representative from each group wrote their conclusions on the whiteboard and the
researcher then guided brainstorming discussions for possible solutions and problem-
solving strategies based on case management theory.
During this processes the main role of the facilitator was to elicit the
participants’ reflections about case management practice and link the essential case
management concepts to their case management practice. The nurses were able to
217
critically reflect on their current problems or difficulties in case management practice
and develop possible strategies to solve their case management practice issues. These
activities helped the participants to link the new concepts they had learned from the
program to their real-life practical work. The facilitator encouraged the participants
to share their practical experiences, and allowed debate about the different
conclusions offered by each groups. Case management theory was used to guide the
possible strategies for barriers and issues of case management practice identified
during the reflection processes. The reflection process lasted approximately one
hour.
The final delivery strategy involved an integrative activity designed to enable
participants to integrate new learning into their daily work. The facilitator used the
concept of action plans during this process. In order to apply the case management
knowledge to their work, all participants were given a task that involved them
thinking about, and then writing down, their action plans relating to learned skills or
activities in their daily case management work. The content included the names of
possible cases, and the planned times and activities during the next two weeks. The
nurses were allowed to discuss their action plan with others or the facilitator, and
could also review the materials offered by the researcher. After the plan was finished,
the researcher encouraged the participants to carry out these planned activities, and
then document any problems or questions raised when initiating the plans. At the
beginning of the following session the researcher then invited participants to share
their new experiences or potential difficulties during the implementation of the action
plan and discuss any changes in their case management practice. Those participants
who shared their planned activity experiences received a verbal reward from the
researcher as a means of encouraging nurses to further use the action plan system.
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7.4 RESULTS OF THE QUANTITATIVE DATA ANALYSIS
This section presents the findings of the tests which assessed the effectiveness
of the CCMCPE program in terms of improving Taiwanese public health nurses’
knowledge, skills and practice regarding case management. Data was obtained from
161 participants. The demographic data included gender, age, educational level,
years in nursing, years in public health nursing, and prior training in case
management.
Among the demographic variables, age and years in nursing in each group
were normally distributed. The data curves for age and years in nursing were nearly
bell-shaped and symmetrical. The skewness and kurtosis values were consistently
between +1 and -1, and the mean and median in each group were very similar (see
Table 7.2). Hence, two sample t tests were used to compare means of the two groups
for age and years in nursing.
However, the data curve of years in public health nursing in the comparison
group was slightly skewed to the right, with a skewness value of 1.01 for the
intervention group and 1.04 for the comparison group. In addition, there was a 40%
difference between the mean of 8.6 and median of 5.0 of years in public health
nursing for the comparison group. The SDs were also over 1/3 of the means in each
group. The distribution of years in public health nursing of each group therefore
differed from normality. A non-parametric test (Mann-Whitney U test) was thus used
to compare the differences between the two groups in years in public health nursing.
Other demographic variables, including educational levels and prior training
in case management, were not examined in this way because categorical variables are
not required to meet this assumption of normality. Chi square tests were used to
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compare the differences between the two groups on educational levels and prior case
management training.
All of the outcome variables were normally distributed for the intervention
and comparison groups because the data curves of these outcome variables were
nearly bell-shaped and symmetrical. The skewness values were consistently between
+1 and -1, the mean and median of the two groups were very similar, and the SD of
each group was not over 1/3 of its mean. Thus the distribution of all of the outcome
variables did not differ from normality for either of the groups. T tests were
performed to evaluate any differences between the experimental and comparison
groups prior to the intervention across the five outcome variables.
As well as the assumption of normality, Levene’s test for homogeneity of
variance was used to check the assumption of equal variances. In the demographic
variables, the results of Levene’s tests showed that equal variances could be assumed
for age, years in nursing and years in public health nursing, as there were no
significant differences in the variances. For the outcome variables, the results of
Levene’s test also showed that equal variances were assumed. Hence, the
assumptions of equal variances for the outcome variables in the two groups were met.
The results of both the descriptive and inferential statistics are presented in the
following section.
7.4.1 Demographic Characteristics of Participants
Descriptive statistics, including frequency distributions, percentages, means
and standard deviations were used to examine public health nurses’ demographic
variables (see Table 7.2 and Table 7.3). The target sample size for the two groups
was 175, however, only 161 participants completed Time 1 and Time 2
220
measurements in the study. There were 85 participants in the experimental group,
from the 87 eligible nurses. This was a 2% attrition rate because two nurses declined
to take part. There were 76 nurses in the comparison group, with none declining to
participate.
The participants were all female with a mean age of 39.2, ranging from 24 to
55 years. Of the participants, 88% held the minimum of a diploma education. Overall,
the nurses were quite experienced (M = 16.7) but this experience ranged from 0.5 to
35 years. They were also experienced in public health nursing (M = 8.6), ranging
from 0.5 to 29 years. The majority of participants (83%) had not attended any
training regarding case management.
Inferential tests were used to examine demographic differences between the
two groups. Results revealed that the intervention and comparison groups did not
significantly differ in regard to their demographic characteristics (see Table 7.2 and
Table 7.3). These results showed no significant sampling bias through the random
sampling procedures.
7.4.2 Descriptions of outcome variables
Five outcome variables were measured in this study, namely case
management knowledge, performing confidence in case management skills,
performance frequency in case management skills, preparedness level in case
manager role activities, and performance frequency in case manager role activities.
The scores on each outcome variable for the intervention and comparison groups
were tallied for pre- and post-intervention.
Descriptive statistics were calculated (Table 7.4). The items in the case
management knowledge scale were summed to obtain a total knowledge (TK) score.
221
Average skill confidence (SC) scores, average skill frequency (SF) scores, average
activity preparedness (AP) scores and average activity frequency (AF) scores were
computed by the mean of the items in each of the respective scales. The results are
shown in Table 7.4.
Table 7.2
Characteristics of participants by group (age and nursing experience)
Characteristic Total
(N = 161)
Experimental
(N = 85)
Comparison
(N = 76)
t p
Age Mean (SD) Min Max Median
39.2(8.2) 24 55 40
39.5(8.3) 24 55 42
38.9(8.1) 24 53 39
0.469 0.6401
Years in Nursing Mean (SD) Min Max Median
16.7(8.1) 0.5 35 18
17.3(8.3) 2 35 19
16.1(7.9) 0.5 32 17
0.913 0.3621
Years in Public Health Nursing Mean (SD) Min Max Median
8.6(8.2) 0.5 29 6
8.6(7.8) 0.5 29 8
8.6(8.6) 0.5 29 5
-0.614 0.5302
1T-test
2Mann-Whitney U Test
Table 7.3
Characteristics of participants by group (gender, education level and prior training).
Characteristic Total
(N = 161)
Experimental
(N = 85)
Comparison
(N = 76)
Chi-Square
N % N % N % χ2 p Gender - - Female 161 100.0 85 100.0 76 100.0 Male 0 0.0 0 0.0 0 0.0 Educational level 3.071 0.546 High school 20 12.4 9 10.6 11 14.5 Diploma 95 59.0 53 62.4 42 55.3 Bachelor 44 27.3 23 27.1 21 27.6 Master 1 0.6 0 0.0 1 1.3 Others 1 0.6 0 0.0 1 1.3 Prior training 0.099 0.753 Yes 27 16.8 15 17.6 12 15.8 No 134 83.2 70 82.4 64 84.2 * = p < 0.05
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Table 7.4
Descriptive statistics and pre-test differences on outcome variables
Characteristic Total (N = 161)
Experimental (N = 85)
Comparison (N = 76)
T-Test
Mean (SD) Mean (SD) Mean (SD) t p Knowledge1
9.1 (2.8) 8.8 (2.9) 9.4 (2.6) -1.346 0.180
Skill confidence2
3.4 (0.5) 3.4 (0.5) 3.4 (0.5) 0.193 0.847
Skill frequency2
3.5 (0.5) 3.5 (0.5) 3.5 (0.5) 0.325 0.745
Activity preparation2
3.2 (0.5) 3.3 (0.5) 3.2 (0.4) 0.416 0.678
Activity frequency2
3.3 (0.5) 3.3 (0.5) 3.3 (0.5) -0.395 0.693
1Possible score 0-18 2 Possible score 1-5
7.4.2.1 Knowledge
Knowledge was measured using an adaptation of the Case Management
Knowledge Scale (Fattorusso & Quinn, 2004), and consisted of 18 multiple-choice
questions. A score of one was given for correct responses and zero for incorrect
responses. To obtain a total knowledge (TK) score, the scores on the 18 items were
simply summed. The possible range of TK scores was therefore 0 to 18. The results
indicated that the participants initially had quite little knowledge of case management,
with pre-test mean of 9.1 (SD = 2.8), equal to 51%. This score is far below the
average accepted score of 60%, which is the usual cut-off point for failure when
evaluating a student’s performance in Taiwan.
There were very similar knowledge levels between the two groups, with
mean scores of 8.8 in the experimental group, and 9.4 in the comparison group.
There was no significant difference in the TK mean scores between the two groups
(t(159) = -1.346, p = .180).
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7.4.2.2 Skill Confidence
The Skill Confidence Scale (SC) asked participants to rate their confidence
when performing a range of case management skills. The SK possible scores ranged
from 1 to 5. To obtain the Skill Confidence scores, the item scores were summed and
the total divided by the number of items (11). The results indicated that the
participants had moderate confidence in performing case management skills, with a
mean score of 3.4 (SD = 0.5). Both groups had very similar levels of confidence
when performing case management skills, as both groups had mean scores of 3.4 (SD
= 0.5), and there was no significant difference at pre-test between the two groups
(t(159) = .193, p = .847).
7.4.2.3 Skill Frequency
The Skill Frequency Scale (SF) asked participants to rate the frequency with
which the used each case management skill. Possible scores ranged from 1 to 5. To
obtain the Skill Frequency scores the item scores were summed and the total divided
by the number of items in the scale (11). The results indicated that the participants
had moderate levels of frequency in performing case management skills, with a mean
score of 3.5 (SD = 0.5). There were very similar levels of frequency in performing
case management skills across the two groups, with both groups having mean scores
of 3.5 (SD = 0.5) and there was no significant pre-test difference between the groups
(t(159) = .325, p = .745).
7.4.2.4 Activity Preparedness
The Activity Preparedness Scale (AP) asked participants to rate their
preparation for performing a range of case manager role activities. Possible scores
ranged from 1 to 5. To obtain the Activity Preparation scores, the item scores were
summed and then the divided by the number of items (27). The results indicated that
224
the participants had moderate levels of preparation for performing case manager role
activities, with a mean score of 3.2 (SD = 0.5). The two groups had very similar
levels of preparation, with mean scores of 3.3 (SD = 0.5) in the experimental group,
and 3.2 (SD = 0.4) in the comparison group. There was no significant difference in
the AP mean scores between the two groups (t(159) = .416, p = .678). .
7.4.2.5 Activity Frequency
The Activity Frequency Scale (AF) asked participants to rate the frequency
with which they used each case manager role activity. Possible scores ranged from 1
to 5. To obtain the Activity Frequency scores, the item scores were summed and the
total divided by the number of items in the scale (27). The results indicated that the
participants had moderate levels of frequency of performing case manager role
activities, with a mean score of 3.3 (SD = 0.5). The two groups had very similar
levels of frequency of performing case manager role activities, as both had mean
scores of 3.3 (SD = 0.5), and there was no significant difference at pre-test between
the groups (t(159) = -.395, p = .693).
7.4.3 Evaluation of Educational Intervention
To explore the participants’ overall evaluation of the educational program,
the proportion of items that received a rating of 4 or 5 by the participants was
calculated. To address the five sub-research questions two-way analysis of variances
with repeated measures on one factor were conducted, in order to evaluate the effect
of the educational intervention on the five outcome variables. Two-way ANOVAs
can be used to assess the effects of one dichotomous (two-group) independent
variable on one quantitative outcome variable (Meyers et al., 2006). The two factors
were Group (intervention and comparison) and Time (pre-test and post-test). The
225
between-subjects factor was Group and the within-subjects factor was Time. The
interaction of Time × Group was also assessed.
In this study, both F values and partial eta squared (η2) values were reported.
The partial eta squared can be treated as an approximate R-squared, which is the
most commonly reported estimate of effect size for ANOVAs (Meyers et al., 2006).
The following section outlines the statistical findings for each of the five research
questions. Refer to Table 7.5 for an overview of the key values.
Table 7.5
Outcome variables scores of pre-test and post-test by two groups.
Characteristic Experimental (N = 85)
Comparison (N = 76)
Mean (SD) Mean (SD) Total Knowledge1 Pre-test 8.8 (2.9) 9.4 (2.6) Post-test 15.3 (2.4) 9.4 (2.5) Skill Confidence2 Pre-test 3.4 (0.5) 3.4 (0.5) Post-test 3.8 (0.4) 3.4 (0.5) Skill Frequency2 Pre-test 3.5 (0.5) 3.5 (0.5) Post-test 3.7 (0.4) 3.4 (0.5) Activity Preparedness2 Pre-test 3.3 (0.5) 3.2 (0.4) Post-test 3.5 (0.4) 3.2 (0.4) Activity Frequency2 Pre-test 3.3 (0.5) 3.3 (0.5) Post-test 3.5 (0.5) 3.3 (0.4)
1Possible score 0-18 2 Possible score 1-5
7.4.3.1 Question 1(Level I)
Question 1: Are the PHNs satisfied with the CCMCPE program? (Level I).
After the program delivery, 97% of participants in the experimental group were
satisfied or very satisfied with this program; 88% believed the program to be
necessary and 90% assessed that the program was helpful or very helpful.
226
7.4.3.2 Question 2.1 (Level II)
Question 2: Is the CCMCPE program effective in improving PHNs’ learning
outcomes? (Level II).
Question 2.1: Is there a difference in self-reported knowledge about case
management between public health nurses who received the case management
continuing professional education program and those who did not?
A two-way repeated measures ANOVA was conducted to evaluate the effect
of the intervention on case management knowledge. The outcome variable was a
total knowledge score ranging from 0 to 18. The Group × Time interaction was
significant (F(1,159) = 180.690, p = .001, partial η2= 0.53). A graph of the
interaction is shown in Figure 7.8.
Post-hoc t tests were conducted to follow up the significant interaction. Total
knowledge mean scores in the post-test of the intervention group (M = 15.3, SD = 2.4)
were significantly higher than the post-test scores of the comparison group (M = 9.4,
SD = 2.5; t(154) = 15.030, p = .001), but there was no significant difference in the
pre-test scores between the two groups (t(159) = -1.354, p = .178).
These results suggest that the intervention did have an effect, such that there
was an increase in the intervention group’s total case management knowledge scores
in the post-test, but no corresponding increase for the comparison group. These
results support the hypothesis that there would be a significant difference in self-
reported knowledge about case management between public health nurses who
received the CCMCPE program and those who did not.
227
Figure 7.8
Graph of time × group interaction on knowledge.
7.4.3.3 Question 2.2
Question 2: Is the CCMCPE program effective in improving PHNs’ learning
outcomes? (Level II)
Question 2.2: Is there a difference in self-reported performance confidence in
case management skills between public health nurses who received the case
management continuing professional education program and those who did not?
A two-way repeated measures ANOVA was conducted to evaluate the effect
of the intervention on skill confidence in case management skills. The outcome
variable was an average skill confidence score ranging from 1 to 5. The Group ×
Time interaction effect was significant (F (1, 159) = 26.033, p = .001, partial η2 =
0.14). A graph of the interaction is shown in Figure 7.9.
Post-hoc t tests were conducted to follow up the significant interaction. Skill
confidence scores in the post-test of the intervention group (M = 3.8) were
significantly higher than the post-test scores of the comparison group (M = 3.4; t
(141) = 4.813, p =.001), but there was no significant difference across the pre-test
scores between the two groups (t (154) = 0.192, p =.848).
Post-testPre-test
18
15
12
9
6
3
0Kn
owle
dge
scor
e
ComparisonExperimental
228
These findings suggest that the intervention made a difference in the skill
confidence scores of the group who received the education program. These results
support the hypothesis that there would be a significant difference in self-reported
performance confidence in case management skills between public health nurses who
received the case management continuing professional education program and those
who did not.
Figure 7.9
Graph of time × group interaction on skill confidence.
7.4.3.4 Question 2.3
Question 2: Is the CCMCPE program effective in improving PHNs’ learning
outcomes? (Level II)
Question 2.3: Is there a difference in level of self-reported preparedness for
case manager role activities between public health nurses who received the case
management continuing professional education program and those who did not?
A two-way repeated measures ANOVA was conducted to evaluate the effect
of the intervention on preparation levels. The outcome variable was average activity
Post-testPre-test
5.00
4.00
3.00
2.00
1.00
Skill
con
fiden
ce s
core
ComparisonIntervention
229
preparation scores in case manager role activities ranging from 1 to 5. The Group ×
Time interaction effect was significant (F(1, 159) = 19.012, p = 0.001, partial η2 =
0.11). A graph of the interaction is shown in Figure 7.10.
Post-hoc t tests were conducted to follow up the significant interaction.
Activity preparation mean scores in the post-test of the intervention group (M = 3.5)
were significantly higher than the scores of the comparison group (M = 3.2), t (156)
= 4.806, p = .001, but there was no significant difference in the pre-test scores
between the two groups (t (159) = 0.418, p = .677).
The findings suggest that the intervention had an effect on the nurses’
preparation level scores. These results support the hypothesis that there would be a
significant difference in level of self-reported preparation in case manager role
activities between public health nurses who received the CCMCPE program and
those who did not.
Figure 7.10
Graph of time × group interaction on activity preparedness.
Post-testPre-test
5.00
4.00
3.00
2.00
1.00
Activ
ity p
repa
ratio
n sc
ore Comparison
Experimental
230
7.4.3.5 Question 3.1 (Level III)
Question 3: Is the CCMCPE program effective in improving PHNs’
performance outcomes? (Level III)
Question 3.1: Is there a difference in self-reported frequency of using case
management skills between public health nurses who received the case management
continuing professional education program and those who did not?
A two-way repeated measures ANOVA was conducted to evaluate the effect
of the intervention on the frequency of using case management skills. The dependent
variable was average skill frequency scores ranging from 1 to 5. The Group × Time
interaction effect was significant (F (1, 159) = 11.824, p = .001, partial η2 = 0.07). A
graph of the interaction is shown in Figure 7.11.
Post-hoc t-tests were conducted to follow up the significant interaction. Skill
frequency mean scores in the post-test of the intervention group (M = 3.7) were
significantly higher than the scores of the comparison group (M = 3.4; t (151) =
3.591, p = .001), but there was no significant difference in the pre-test scores
between the two groups (t (155) = 0.325, p = .746).
These results suggest that the intervention had an effect on the nurses’
performing skill frequency scores. These findings support the hypothesis that there
would be a significant difference in self-assessment of performing frequency in case
management skills between public health nurses who received the CCMCPE
program and those who did not.
231
Figure 7.11
Graph of time × group interaction on skill frequency.
7.4.3.6 Question 3.2
Question 3: Is the CCMCPE program effective in improving PHNs’
performance outcomes? (Level III)
Question 3.2: Is there a difference in level of self-reported frequency of using
case manager role activities between public health nurses who received the case
management continuing professional education program and those who did not?
A two-way repeated measures ANOVA was conducted to evaluate the effect
of the intervention on frequency of using case manager role activities. The outcome
variable was activity frequency scores ranging from 1 to 5. The Group × Time
interaction effect was significant (F (1, 159) = 9.760, p = .002, η2 = 0.06). A graph of
the interaction is shown in Figure 7.12.
Post-hoc t-tests were conducted to follow up the significant interaction.
Activity frequency mean scores in the post-test of the intervention group (M = 3.5)
were significantly higher the scores of the comparison group (M = 3.3; t (159) =
2.964, p = .004), but there was no significant difference in the pre-test scores
between the two groups (t (153) = -0.393, p = .695).
Post-testPre-test
5.00
4.00
3.00
2.00
1.00Sk
ill fr
eque
ncy
scor
e
ComparisonExperimental
232
These findings suggest that the intervention made a difference in nurses’ self-
reported frequency scores of using case manager role activities. These results support
the hypothesis that there would be a significant difference in self-reported frequency
in case manager role activities between public health nurses who received the
CCMCPE program and those who did not.
Figure 7.12
Graph of time × group interaction in activity frequency score.
7.5 SUMMARY OF THE QUANTITATIVE RESULTS
This section has reported the results of the statistical tests on the pre- and
post-scores of the experimental and comparison groups. These findings were
discussed in relation to each of the five research questions. This section provides a
summary of those findings. All of the participants were female, and the group as a
whole had a mean age of 39. Overall, they were quite experienced in nursing and
public health nursing, but there were wide differences in terms of working seniority,
which ranged from 0.5 to 35 years. The two groups were not significantly different in
age, nursing education level, the length of time spent in nursing, public health
nursing and prior training in case management.
Post-testPre-test
5.00
4.00
3.00
2.00
1.00
Activ
ity fr
eque
ncy s
core
ComparisonExperimental
233
Before the intervention the participants had quite low knowledge levels
regarding case management and moderate levels of skill confidence, skill frequency,
activity preparation and activity frequency. There were no significant differences at
pre-test between the two groups on the outcome variables. The five research
questions compared the differences in the mean scores of case management
knowledge, skill confidence, skill frequency, activity preparation and activity
frequency between the intervention and comparison groups, both pre- and post-test.
Results revealed that the mean scores of these outcome variables in the post-test were
significantly higher for the intervention group than for the comparison group. Most
participants stated that they were satisfied with the program and believed that it
program was both necessary and helpful.
The psychometric data of the Case Management Knowledge Scale was also
examined, because no tests of this version of the case management instrument had
been undertaken. The results showed different K-R20s between the two groups in the
pre-tests and post-tests, which suggests that K-R20 might not a good indicator of
reliability in this study. However, test–retests showed a significant Person correlation
of .63 (p < .01) in the comparison group, and adequate content validity (0.87)
according to the expert review. These ratings suggest that the Case Management
Knowledge Index used in this study had satisfactory stability and content validity.
7.6 FINDINGS FROM THE QUALITATIVE DATA
This section presents the results of the focus group conducted to explore the
impact of the educational intervention on public health nurses’ concept of case
management and their case management practices. Participants’ feedback on the
program itself is also discussed. The results comprise four main sections: PHNs’
234
understanding of case management; how current case management practices have
changed; the factors influencing those changes; and their general feedback on the
program. The categories of the four research sub-questions are detailed in Table 7.6.
Table 7.6
Categories of the focus group after the educational intervention
Themes Categories
Current case
management
knowledge
Linking resources through coordinating
Screening cases; Identifying available resources; Offering information; and
Linking resources
From screening needed cases to evaluating and ending cases
Screening cases with multiple needs; Assessing; Planning; Coordinating;
Monitoring; Evaluation and end cases
Current case
management
practice
Follow case management process
Screening;
Assessing and identifying problems;
Identify available resources;
Offer direct services;
Linking resources; Using communication skills to coordinate
Evaluation. Evaluating outcomes of case management
Focusing more on the quality of case management
Emphasis on outcomes of case management;
More confidence;
Broader CM practice.
Factors
influencing
changes
Policy
Target managed case numbers
Time limitation
For annual evaluation paper work
High work load
Multiple responsibilities not just case management work
Engaging and managing many cases
Feedback on
program process
Learning activities are good, interesting and attractive.
Obtained a lot
It was helpful
Offering orientation programs for new staff
235
7.6.1 Current Case Management Knowledge
Participants in the focus group were asked to describe their knowledge of
case management. Two main categories were identified, namely ‘linking resources
through coordinating’ and ‘from screening needed cases to evaluating and ending
cases’. The participants understood case management as the ability to link resources
to needed cases through their coordination. This concept incorporated the screening
of cases, identification of available resources, offering information, and linking
resources through coordinating. This was evidenced by the participants’ following
statements (the sub-categories related to the statements are presented in brackets).
My concept of case management is to address the needs of a
particular case and deal with such needs appropriately. For example,
after evaluating the needs of each particular case, we will link the
community resources, and help them to look for such resources as
well as inform them. (Identifying available resources; offering
information)
There is a need to search for the necessary cases, and then carry out
some healthcare protection and resources link-up. (Screening cases;
linking resources)
There are also some coordination aspects. We need to carry out our
coordination work on their behalf. (Linking resources through
coordinating)
In addition, the participants stated that case management ranged from
screening needed cases to evaluating and ending cases. The detailed process involved
236
screening cases with multiple needs; assessing; coordinating; monitoring; evaluating
and ending cases. The example statements below reflected this process.
From screening the cases before accepting them, collecting
information to evaluate the status of the case and looking at the needs.
(Screening cases; assessing)
Carry out the necessary link-ups to the available resources, and find
out which units or organizations are willing to participate and help.
(Coordinating)
Finally, it is necessary to monitor and evaluate the services in the
course of the case management, in order to determine whether the
services should continue or be terminated as a result of the goals
having been achieved. (Monitoring; evaluating and ending cases)
7.6.2 Current Case Management Practice Change
Following discussion of their understanding of case management, the
participants talked about their current case management practices compared with
those before the educational program. In relation to changes in current case
management practices, analysis of the focus group data indicated that the participants
tended to ‘follow the case management process’ more often, and ‘focus more on the
quality of case management’. These were evidenced by the nurses reporting changes
reflecting a closer following of the case management process to conduct case
management work, including screening, assessing and identifying problems, offering
direct services, identifying available resources, linking resources through
coordinating, and evaluating. The participants made the following statements.
237
We accept the cases only if there are multiple needs.” “I make some
changes to the guidelines for accepting cases and terminating cases.
(Screening)
After discovering the case problems, I go directly into the service
aspects, as well as linking-up with the resources. Currently the direct
services aspect is gradually being reduced, while the link-up with
resources has been increased. (Assessing and identifying problems)
Currently the direct services aspect is gradually being reduced, while
the link-up with resources has been increased. (Offering direct
services; linking resources)
In reality, for the planning aspect, we do not usually write down our
case evaluation, plans and execution. However, we still follow the
case management process. (Evaluating)
Another category referred to ‘focusing more on the quality of case
management’. After the educational intervention, the public health nurses
emphasised outcomes of the case management process more than the numbers of
cases they managed. Also, they expressed that they had more confidence to conduct
case management practices because they know how to practice, what they were
doing, and they had more complete concepts.
In the past we accepted all cases that had medical anomalies or cases
that were transferred to us, but we do not do this nowadays. We know
that we need to focus more on the quality aspects of case management
rather than the quantity aspects.
238
Nowadays, we put more emphasis on quality outcome evaluation, and
we are also more aware as to how to explain what we are doing.
The area to change is to find out the characteristics of my speciality
and to focus more on expressing the quality results. This enables
other people to see the concrete results of case management, and to
see that it cannot be replaced by other professions.
7.6.3 Factors Influencing Changes
The participants were asked to discuss any factors which had influenced their
changes in case management practice. Barriers to changing case management
practice after the educational intervention were identified as ‘policy’, ‘time
limitation’ and ‘high work load’. The participants stated that they still need to follow
the target case numbers that the health department required. Also, all specific
populations with chronic diseases, mentally ill patients and older adults living alone
needed to be managed. In other words, they needed to manage all of these cases, not
just screening of multiple needs cases. These issues impacted on changes to case
management.
In addition, the course was held in a period during which annual reports
needed to be submitted. This may have resulted in the nurses having limited time in
which to conduct the planned activities from the education sessions. Finally, a
regular high work load with multiple responsibilities could also influence the
implementation of changes in case management practices. These were evidenced by
the following statements.
239
We know the importance of screening through the cases, but we need
to look at the quantitative targets and achieve these targets. The
health industry currently still focuses on the quantitative targets for
case management, which may not be possible to meet if we put what
we have learnt into practice. (Policy)
The busiest period for a health services centre is October, November
and December. There are many items to close, evaluations to be made
and reports to be filed. (Time limitation)
Our current workload is really very heavy. There will sometimes also
be some temporary duties or duties to handover or temporary
problems that require immediate attention. All these would affect the
amount of time that we have for case management. (High work load)
7.6.4 Overall Program Feedback
All the participants were invited to comment and evaluate the overall
program. The program received overwhelmingly positive feedback. The participants
indicated that the learning activities were interesting and attractive. They stated that
they acquired more complete and systematic concepts from the program. They also
stated that they changed their understanding and their case management practice on
the basis of the program. Further, the participants suggested that the Health Ministry
should arrange for new staff to complete the course due to its usefulness. These
issues were demonstrated by the following comments.
The learning activities organised by the lecturer are very good, very
attractive, very interesting, and are relevant to our work. The learning
outcomes are good.
240
We have benefited very much from attending this course. In the past,
there has not been such a comprehensive and systematic course.
Right, my colleagues all say it was very lively, and very effective.
I suggest that the Health Ministry sends new staff for such courses,
because they are very helpful, and we are very fortunate to have
attended this course.
The focus group discussions were used to answer the last research question:
‘Are there changes in case management practice for those who attended the
collaborative case management continuing professional education program? If yes,
how has practice changed? If not, what factors hinder changes?’
To summarise the results, the participants felt that they had developed a more
complete and theory-based concept of case management. They were aware that case
management seeks to link available resources to the cases that require them. They
realised that case management practice is actually a process consisting of multiple
activities. Reported practice changes were consistent with their new understanding of
case management. These changes in practice meant that they followed the case
management process more closely and improved the quality of their case
management practices. However, some barriers still existed to changes in their
practice. The evidence suggests that the collaborative case management education
program improved participants’ awareness of case management and helped them
achieve better quality and theory-based case management practice.
The next chapter will summarise the findings of the study and discuss issues
arising from the study, including limitations and implications of this research.
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CHAPTER EIGHT
DISCUSSION AND CONCLUSION
The purpose of the study was to develop, deliver and evaluate the effects of
the collaborative case management continuing professional education program for
public health nurses in Taiwan. The study was divided into three phases and was
guided by an integrated theoretical framework as a means of developing,
implementing and evaluating the educational program. Phase One conducted focus
group discussions in order to assess the educational needs of Taiwanese PHNs. Phase
Two developed a collaborative education program based on the findings of a
literature review and the needs assessment. The initial program evaluated by an
expert panel and pilot testing was undertaken for various improvements. Phase Three
implemented and evaluated the program using an experimental research design and
mixed evaluation methods. Three outcome levels were assessed, namely satisfaction,
learning and performance. The participants in the study were PHNs employed in
health service centres in Taipei City. The educational program itself involved 16
hours of workshops, conducted during the participants’ work time and at their
workplace.
The previous chapters have described the findings of the three different
phases of the study. These phases first assessed the educational needs of the nursing
population under study, and then developed and evaluated a collaborative case
management education program to improve the public health nurses’ (PHNs)
knowledge, skills and practices related to case management. Phase One identified
gaps in case management knowledge and practice of Taiwanese PHNs, and also
assessed their preferred learning methods. Phase Two developed a collaborative case
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management program to prepare PHNs for the essential knowledge, skills and role
activities of case management based on findings from the literature review and the
needs assessment. Mixed evaluation methods were used in the final phase to gain a
comprehensive understanding of the impact of the collaborative case management
continuing professional education program. Three levels of outcomes, including
satisfaction, learning and performance, were explored to determine the effect of the
program.
From a quantitative perspective the educational intervention significantly
improved PHNs’ case management knowledge, performance skills confidence,
preparedness for case manager role activities, frequency of using case management
skills, and frequency of using these role activities. All the hypotheses were
confirmed through use of inferential statistics. From a qualitative perspective,
changes in the performance of the case management process and an increased focus
on the quality of case management provided were described as improvements by
participants in the final focus group discussions. These comments provide support
for the value of the educational program in terms of changing case management
practices, even though it is also clear that some factors still hinder practice changes.
Although statistically significant improvements were observed across the
performance outcome measures, including skill frequency and role activity frequency,
further work is required to devise a program that achieves greater practice changes
and provides for evaluation of follow up effects of the educational program. This
chapter discusses the results of the evaluation study according to the three levels of
outcomes: satisfaction, learning and performance of case management practice. The
strengths, limitations and implications of the current work are also presented, and
final conclusions drawn.
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8.1 LEVEL I: REACTION EVALUATION
One of the research questions examined the effect of the intervention on
reaction outcome (Level I), which explored ‘Are the public health nurses satisfied
with the CCMCPE program?’ The hypothesis that PHNs who received the CCMCPE
program were satisfied with the CCMCPE was confirmed in the study.
The present study evaluated nurses’ reaction to the educational program using
four-point rating scales. The results show that, after the delivery of the program, 97%
of participants in the experimental group were satisfied or very satisfied with the
program, 88% viewed the program was necessary and 90% rated the program as
helpful or very helpful. This positive reaction from participants is consistent with
previous studies (e.g., Dickson, 2003; Smith, 1997; Weisman & Lamberti, 2002).
This quantitative feedback is consistent with the results obtained from the qualitative
evaluation, as the program received overwhelmingly positive feedback from the
focus group. During the focus group the participants indicated that the program’s
learning activities were interesting, well prepared and relevant to their work. Further,
the PHNs considered they had benefited from attending this course in terms of their
future application of case management.
According to existing studies by Sekowski (2002) and Colquitt and
colleagues (Colquitt, LePine, & Noe, 2000), there are not necessarily significant
relationships between reaction results and other elements of a course (learning and
performance). Thus in this study the nurses’ reactions may not be predictive of
outcomes on the other levels: learning outcomes or performance outcomes. However,
reaction level results still offer useful information in the process of evaluating an
educational program, for instance regarding facilitator effectiveness, course design,
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course delivery and the educational program itself. This information assists educators
when revising their education programs. Thus the participants’ reactions in this study
provided valuable evidence that the collaborative case management education
program was beneficial.
It is likely that one reason for the nurses’ positive reactions to the program is
the careful needs assessment that was undertaken (using focus groups) which initially
identified PHNs’ preferred learning methods and needs. The program was carefully
developed using this information to address their learning needs in case management
education. The majority of the participants did not have any prior systematic training
in case management, and thus the program was timely to meet their emergent needs
in their daily practice. Hence, most participants’ rated it necessary. Further, the
program was offered during the nurses’ work time, at their place of work, which
meant that the PHNs could study case management at a time and place suitable for
them. It is well known that opportunities and cost of continuing education are
barriers to CPE (Nolan et al., 1995). Finally, the program draws on the PHNs’
experience in case management and links the theory to their practice, which has also
meant that the program has been closely relevant to their daily work. The education
intervention directly helped the PHNs develop strategies to solve problems arising
from their case management practice. The research question ‘Are the public health
nurses satisfied with the educational program?’ was thus answered in the affirmative.
8.2 LEVEL II: LEARNING OUTCOMES EVALUATION
Another research question examined the effect of the educational intervention
on learning outcomes (Level II), namely ‘Is the CCMCPE program effective in
improving PHNs’ learning outcomes?’ Three further sub-questions were explored.
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The hypotheses that the educational intervention would significantly improve
participants’ learning outcomes in terms of case management knowledge, skill
performance confidence and their preparedness for the case manager role activities
were confirmed.
Nurses are required to have a certain level of professional knowledge and
have acquired specific skills regarding case management in order to carry out their
clinical and professional responsibilities. Case management practice requires
knowledgeable nurse case managers in order to achieve good case management
outcomes. Insufficient training and insufficient knowledge were identified as barriers
faced by nurse case managers in providing case management services (Wathen,
2005). As new case managers, nurses confirmed that they desired and benefited from
guidance and support from more experienced and knowledgeable mentors. Thus the
current study examined whether there were any changes in PHNs’ case management
knowledge and confidence levels in performing case management skills after the
intervention. The overall goal of the educational program is to prepare PHNs for case
management practice, thus changes in their preparation for case manager role
activities following the program was also examined.
The current study measured PHNs’ performance confidence in case
management skills both before and after the program was implemented. The purpose
of measuring personal efficacy beliefs is to predict the performance of the behaviour
by an individual (Schwarzer, 1992). Positive correlations between nurses’ confidence
and performance/competence levels were demonstrated in Wathen’s research
(Wathen, 2005). A learning process is a strategy which enhances confidence, and
case managers identified that their increased confidence came from continuing
education rather than prior educational preparation. Thus nurses’ confidence levels
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were expected to increase after the continuing education program implemented in
this study.
The results of the study confirm the hypotheses that the educational
intervention in the present study successfully improved the PHNs’ knowledge of case
management, their skill performance confidence and their preparation for practice.
This improvement occurred through the collaboration between the nurse academic
who designed and administered the study and practicing nurses, suggesting that the
collaborative education program was effective in achieving the learning outcomes.
The enhancement in knowledge and skills observed in the current study is consistent
with studies previous studies by Vinton (1993), Sheaffer et al. (1998), Smith et al.
(1998), Shaw et al. (2001), Donoghue et al. (2004), and Howell et al. (2004). The
current study also offered additional evidence for the success of the educational
intervention by enhancing the participants’ feeling of preparedness for their case
management practice. The rationale for this aspect of the evaluation was that the
educational intervention was aimed at preparing the nurses for acting in their case
manager roles, and thus this should in some way be directly measured in the study.
The results also suggest that the educational intervention achieved its overall
expected goals.
The improvements in knowledge and confidence levels discussed above were
also supported by findings from the focus group conducted after the program was
completed. Participants reported that they had a more complete understanding of
case management concepts after the intervention and that their conceptual
understanding of case management had changed. The education intervention also
improved participants’ confidence in using case management approaches and their
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practices, as they reported increased confidence when coordinating care for clients
and their families, and heightened confidence in relation to skills learned in practice.
The findings of the current study are in contrast to Howell and colleague’s
(2004) education program evaluation study aimed at case managers for specialty
populations. That study found no significant increase between palliative care
knowledge pre- and post-intervention (but did find a significant increase in
knowledge between the post-program measure and an assessment made three months
later). One likely reason for the difference in findings between the two studies is that
the participants in the present study began from a very low level of knowledge, and
thus could easily improve, whereas there was a high level of knowledge prior to
course participation for those nurses in the study by Howell and colleagues.
Again, it is likely that the significant improvement in knowledge, confidence
in skills and preparedness for role activities from the study was positively affected by
the application of the findings from the needs assessment conducted in Phase One.
That is, the program was designed to fit the participants’ educational needs and used
interesting and effective methods. Furthermore, learning strategies were specially
designed to achieve each target learning outcome variable (see Table 8.1). In order to
enhance PHNs’ case management knowledge, knowledge gaps had been identified
through the initial needs assessment, which meant the facilitator could address the
particular gaps in the PHNs’ knowledge. A game was used to stimulate participants’
motivation to learn and reveal the gaps in their current knowledge, and also helped
the PHNs concentrate on the following input activities and interactive lectures. The
interactive lectures allowed participants to update their case management knowledge
and to combine it with their work experience in case management practice. This
enhanced their acquisition of the basic case management concepts presented in the
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program and significantly improved their knowledge levels in case management. In
order to ensure that the PHNs did not miss any important concepts if they had to be
absent during a session, the program facilitator addressed the key concepts at the
beginning of the four sessions. All the learning strategies designed for the program
contributed to the positive outcomes in terms of enhancement of case management
knowledge.
Table 8.1
The strategies used to enhance learning outcomes
Outcome variable Learning strategies Program design
Knowledge 1. Knowledge gaps identified
2. Motivated games
3. Updated knowledge
4. Repeated key concepts
• Needs assessment and inductive
learning activities
• Inductive learning activities
• Input activities
• At the beginning of each session
Confidence in
Skills
1. Interactive lectures, case
example, demonstration, role
plays, case studies
2. Critical reflection through
guided group discussions
3. Action plan encouraged
• Input activities
• Implementation activities
• Integrated activities
• At the beginning of each session
Preparedness for
role activities
1. Practice gaps identified
2. Familiar with role activities
3. Critical reflection through
guided group discussions
4. Action plan encouraged
• Needs assessment
• Inductive activities with games
• Implementation activities
• Integrated activities
• At the beginning of each session
In a similar way, the input activities incorporated multiple learning strategies
in order to enhance the PHNs’ performance skills in case management, including:
case examples, demonstrations by the facilitator (especially on the topic of
communication skills) and role plays. These multiple learning strategies were used to
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enhance the nurses’ case management skills. Additionally, many different strategies
were used to achieve better preparation for PHNs’ case management practice.
Through the advanced needs assessment aspects of case management practice were
identified, including the lack of case identification, the identification of available
resources, and the outcome evaluation within case management. These areas were
addressed by the facilitator. A set of cards, consisting of all the case manager role
activities, were given to the PHNs. They were asked to use the cards to categorise the
activities into six categories: the six steps of the case management process. This
game successfully introduced the PHNs to their role activities. The activities were
introduced again during the interactive lectures. In this way, all of the practice
activities were recycled, hence improving learning. Careful assessment of needs in
case management and careful planning is thus required to achieve the expected
learning outcomes, and the multiple strategies used here directly contributed to the
positive outcomes of the current study.
Although the current study generated similar results to those reported by
Vinton (1993), Sheaffer et al. (1998), Smith et al. (1998), Shaw et al. (2001),
Donoghue et al. (2004), and Howell et al. (2004), these other six studies used only
one group to evaluate the effect on knowledge or confidence levels for nurses after a
training program. In contrast, the current study used randomisation of two groups,
with pre- and post- testing, with a large sample size of 161 participants. These other
studies also failed to report the psychometric data associated with the instruments
used. The current study, however, used mixed methods and an experimental research
design to evaluate the impact of the educational program on enhancing learning
outcomes and psychometrically tested all instruments used in the study. These
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strengths mean that the results of the study offer more powerful evidence to
demonstrate the learning effect of the educational intervention.
On the other hand, the follow up effects of the educational intervention and
the latency effects are unknown, as this study did not measure any long-term effects
because of time limitations. Therefore, further research should be undertaken
assessing the effects of this program over more substantial time frame to determine
the longer term effects of the educational intervention. This further research would
enhance the data gathered during this study.
8.3 LEVEL III: PERFORMANCE OUTCOMES EVALUATION
The final research question examined the effect of the intervention on
performance outcomes (Level III), namely ‘Is the CCMCPE program effective in
improving PHNs’ performance outcomes?’ Two sub-questions were also determined.
These consisted of hypotheses that the educational intervention would significantly
improve participants’ self-reported performance outcomes in terms of improving the
frequency of using case management skills and case manager role activities. These
hypotheses were confirmed, in that there were recorded changes in case management
practice.
The real value of continuing professional educational programs is to change
practice and to achieve better quality of care. Few studies in case management
continuing education programs have examined their effects in terms of changes in
case management practice. The present research determined that the educational
intervention impacted on participants’ reported frequency of using case management
skills and case manager role activities, confirming hypotheses that the intervention
significantly increased participants’ use of case management skills and role activities
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(in contrast to the comparison group). The PHNs reported in the focus group that
they had changed to “follow the case management process” more often, and to “focus
more on the quality of case management”.
Only one other study (Connors, 1992) has measured the frequency of use of
case management skills in a study like this, however, no differences were found in
that research. No study has evaluated the frequency of using case manager role
activities in the field. The current study used both quantitative and qualitative
methods to evaluate the impact of the educational program on PHNs’ performance
outcomes. This is a major strength of the study, and offers more powerful and
comprehensive evidence to demonstrate the effect of the educational intervention on
PHNs’ case management practice. Hence, the results of the current study contribute
to the current knowledge in terms of the evaluation of nurses’ performance outcomes
in case management practice after an educational intervention.
The performance outcomes observed in this study are likely to have occurred
because of the use of learning strategies drawn from transformative learning: namely
critical reflection and the use of action plans. Mezirow’s transformative learning
theory emphasises the key role of reflection and action in learning and
transformation. Transformative learning offers a means by which CPE providers can
integrate learning and context within educational activities. Hence, the
transformation to performance may emerge from using critical reflection and action
plans in the current study.
Critical reflection contributed to the current program’s ability to break down
PHNs’ barriers and difficulties in performing case management practice. Guided
group discussions and brainstorming during the critical reflection activities allowed
the participants to develop possible strategies and skills to perform case management
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work. In addition, the study incorporated integrative learning activities which used
action plans to encourage nurses to apply learned skills and role activities in their
workplace. The benefits of these activities were demonstrated by remarks made
during the focus group discussions after the education program. The participants
indicated that the learning activities were very good, very effective, very interesting,
and were relevant to their work; they considered they gained a lot from the course
and that the course was helpful. That practice changes occurred following the
education intervention was also supported by the findings from the focus group
discussions. However, there were still some factors reported in the focus group
discussion that may still hinder the frequency of using case management skills and
role activities.
In the focus groups the PHNs confirmed that they tended to ‘follow the case
management process’ more often, and ‘focus more on the quality of case
management’ after the program was implemented. These were evidenced by nurses’
reported changes that reflected a closer adherence to the case management process
when conducting case management work. After the educational intervention, the
PHNs transferred their focus to the outcomes of the case management process more
than the number of cases they managed. Thus both the quantitative and qualitative
results of this study support the performance outcome effect of the educational
intervention.
There were several other factors influencing the nurses’ changes in
performing their case management practice, including the policies of their work
organisation, their high work load and the timing of the CPE. The participants in the
focus group stated that they still needed to follow the target case numbers that the
health department required. Even though the PHNs understood case management and
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what a nurse case manager should do, the organisational policies also need to change
in order to focus on the quality of case management practice rather than the target
numbers that the PHNs manage. In addition, the intervention was held at the end of
the year when the public health nurses’ workload and evaluation paperwork were
high, possibly hindering changes in case management practice. Hence, future
educational programs should consider the timing of the implementation and the
implications of these factors on practice. The results offer additional evidence
supporting the validity of the proposed framework and suggest minor revisions to the
educational factors adopted in this framework.
The theoretical framework identified the influencing factors as variables
affecting the effectiveness of the continuing education program. The framework also
considered the structure of the educational system in program development and
delivery. The learning process used in the program was based on a needs assessment
conducted before program delivery, and adopted evidence from the literature review.
It is believed that all of these considerations produced a significant improvement in
participants’ reaction to the program, their learning, performance outcomes and the
changes in their practice. The findings support the framework used in this study.
After conducting this study, it is suggested that future researchers should consider the
timing of program delivery as a additional educational factor influencing the
effectiveness of continuing education. The role of organisational support and current
standard practice across each centre have been confirmed as important organisational
factors influencing practice changes reported after the educational program.
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8.4 STRENGTHS OF THE STUDY
The current study had several strengths which allow the information gathered
to contribute to knowledge about the effectiveness of case management education
programs. Firstly, the current study addressed an identified weakness in existing
programs in that it first conducted a needs assessment with potential participants, and
this information then formed the purpose and objectives of the present study. Hence,
the study clearly addressed focused research questions and the results of the study
were directly related to the study’s purpose, in order to develop, implement and
evaluate a collaborative case management continuing professional education
program.
Secondly, the study used an integrated theoretical framework based on a
structure–process–outcome model to guide the program development,
implementation and evaluation. Through a detailed review of existing evaluation
studies and careful planning to consider factors influencing effectiveness, the study
based on the integrated framework successfully achieved the outcomes of the
educational intervention.
Thirdly, the development of the educational intervention went through four
main procedures to ensure its effectiveness, namely evidence from the literature
review, a needs assessment, an expert panel review and pilot testing. Through focus
group discussions, current gaps of knowledge and practice in case management and
PHNs’ educational needs were confirmed. The needs assessment in case
management education and the case management program were the first work in
Taiwan in this area for nursing professionals. In addition, the study reviewed
evidence on effective learning strategies based on a relevant learning theory to
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develop the program. The program’s effectiveness and appropriateness were further
reviewed by an expert panel and pilot tested. All these procedures contributed to a
well designed and well developed program.
Fourthly, in terms of program implementation, evidence-based educational
practices using multiple learning strategies and strategies from transformative
learning contributed to the potential transfer of performance to case management
practice. The collaborative case management continuing professional education
(CCMCPE) program was the first program offered for PHNs in this area providing
evidence-based resources for case management education. The current study was the
also first work of this kind to examine a collaborative case management education
program for PHNs. This solid theoretical basis and careful planning may explain why
the program was so successful in significantly improving participants’ learning
outcomes and performance.
The current study used a rigorous research design and carefully prepared
procedures in an effort to reduce potential bias within the study, thus addressing
deficits in previous research undertaken in this field. Randomisation of participants
(across workplaces) into the experimental and comparison groups (and use of both
pre- and post-tests) was undertaken to reduce possible bias and ensured that the two
groups were very similar at the start of the educational intervention. In fact, the only
identifiable difference between the groups was the educational intervention under
investigation. In addition, the sample was representative of PHNs in Taipei City
because the study included almost all the public health nurses in this city. The sample
size was far larger than other previous studies in the area. These methodological
strengths thus helped to reduce the effect of any potential bias or confounds within
the study. In addition, the study used psychometrically validated instruments, which
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had pilot tested, and used a mixed method to determine the effectiveness of the
educational program. The tools used to examine nurses’ case management
knowledge, case management skills, and case manager role activities were translated
and tested in Taiwan.
In terms of internal validity, the study used many strategies to reduce
potential sources of bias (e.g., testing, implementation and attrition bias). When
collecting the baseline data, the researcher used the same explanation with both
groups, namely that the pre-test could help the researcher identify participants’
knowledge gaps and that the work would help to develop a suitable program for the
two groups. During quantitative data collection an anonymous questionnaire was
used, an envelope was provided for each participant when they had completed the
questionnaire, and a third person (a research assistant) was used to collect these
envelopes. These steps should have reduced potential social desirability or testing
bias. Each course session and focus group was conducted by the same facilitator, and
followed a very structured plan and guideline to reduce potential bias. Also, many
strategies were used to reduce attrition bias. The course contact hours could be added
to the PHNs’ annual continuing education hours. All the PHNs in the experimental
group were encouraged to participate by their head nurses and director. The PHNs
were allowed to use another centre to catch up with any missing course. These
strategies contributed to the very low attrition rate. All of these research procedures
enhanced the internal validity of the current study.
Finally, the study evaluated three different levels of educational outcomes
using a mixed method to explore the effect of the program more comprehensively.
The study examined PHNs’ reaction, learning and performance outcomes using both
quantitative assessment (questionnaires) and a qualitative approach (focus group).
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The results demonstrated the effectiveness of the program in terms of improving
learning outcomes and changing case management practice. The results also
contribute to a broader knowledge about the effectiveness of educational programs in
general.
The strengths incorporated into this research have made steps to addressing
the gaps or deficits identified in prior research in this field. Hence, this study
contributes new data to the field of effective design and implementation of
collaborative case management education programs. The rigorous research design of
this study contributed strongly to the effectiveness of the collaborative educational
program, in terms of changing PHNs’ knowledge, skills and practice in relation to
case management. Also, the case management educational program offers evidence-
based resources for PHNs and nursing education. The instruments used were tested
in Taiwan, and had appropriate psychometric properties, allowing both replication of
other studies and comparisons of the findings with previous results. These strengths
supported the appropriateness of the design, implementation and evaluation of the
education program and confirmed that this study had positive outcomes for
participants.
8.5 LIMITATIONS OF THE STUDY
Despite the many measures that were taken to ensure a rigorous design and
best practice within this study, some issues were beyond control of the researcher.
Therefore this study still had several limitations, namely related to internal validity
and data collection procedures. First, the researcher and the participants were not
blinded to the intervention, due to the practical difficulties of conducting blind
research. The researcher attempted to reduce possible bias and contamination by
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staggering the implementation of the program, with the group who first received the
course acting as the experimental group, and the later group acting as the comparison
groups. However the participants, particularly those with research training, may have
recognised that they had been allocated to the experimental group or the comparison
group. It was also obvious to the experimental group that they were receiving an
education program that was not usually offered to them. Thus it was not possible to
eliminate an attention effect, namely that the experimental group received novel
attention through participating in the education program.
Another point that may have introduced bias was the quantitative data
collection method used in the study, which was self-report via a questionnaire. The
use of self-report measures always introduces potential bias into experimental
findings. The sources of potential bias in this context are response distortion (such as
social desirability) and moderacy response style bias. Further, as the researcher was
an academic (and thus possibly perceived as high achieving), the PHNs might have
changed their responses to give a good impression, hence causing social desirability
bias. However, the researcher had no prior relationship with the PHNs, and the
researcher explained that the results could not have any effect on their future work,
which to some degree may have addressed this potential issue. The skill confidence,
activity preparedness, skill and activity frequency of the PHNs were all
approximately moderate on the scales, which means that the results may have been
affected by the moderacy response style bias when using the five-point Likert scale.
However, the use of both qualitative and quantitative data in this study does, to some
degree, deal with the limitations arising from the moderacy response style bias,
because the qualitative data provides a greater and deeper exploration of the issues
raised by the nurses.
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As discussed previously, the researcher acted as both an investigator and
educational facilitator. This may have influenced participants’ responses in focus
group discussions. However, the researcher used standard collection procedures,
including a focus group discussion guide, and participants completed anonymous
questionnaires and then delivered them to the research assistant. These measures
aimed to reduce potential bias due to the dual researcher/ facilitator role.
The final limitation of the study was that it did not incorporate either a level
four evaluation (such as patient outcomes) or assess the follow up effect after the
educational intervention. Both of these measures were not taken due to practical
issues and time limitations. For instance, there are many external factors influencing
patient outcomes and there is a lack of standardised practice between centres. This
made it very difficult to determine if any effect observed in terms of patient
outcomes was due to the education program or other external factors. The
sustainability of the PHNs knowledge and practice changes after the educational
intervention are unknown because this study did not measure any follow up
outcomes. Hence, further research measuring patient outcomes and incorporating
follow up measures would enhance the results of the present study.
8.6 IMPLICATIONS
The findings of this thesis have implications for three main areas of study,
namely education, practice and research. These are discussed below in turn.
8.6.1 Implications for Education
Taiwanese PHNs need additional educational preparation to improve
professional knowledge and skills and hence to potentially achieve better case
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management outcomes. Taiwanese PHNs’ knowledge and skills related to case
management was not well understood in the past, but this study offers important data
in this field. According to this study, 83.2% of the PHNs had no prior education in
case management. The focus group discussions and pre-testing conducted in this
study identified that the PHNs had a limited understanding of the concepts of case
management with a low score (51%). They had very low scores on the knowledge
test (46%) and only moderate confidence and frequency of performing case
management skills, and preparedness for case manager role activities. This supports
the need for additional education to improve PHNs’ professional knowledge and
skills related to case management.
Another important implication of this study is that the CCMCPE program
could be replicated for PHNs and other nurse populations working with case
management. This study also demonstrates that the CCMCPE program could be an
evidence-based educational resource for nursing education in general. The CCMCPE
program could be adapted for PHNs in other areas or other countries, and nurses
working in hospitals or long-term care institutions. The collaborative educational
program designed in this study could be adopted by nurse educators and academics
to help nursing students and nursing staff to improve their knowledge, skills and case
management practices. The content and materials used in this study can now be
adopted as teaching materials, based on the research evidence described here.
Furthermore, collaboration between nursing academics and nursing practice
using multiple leaning strategies appears to successfully meet PHNs’ expanded roles
in the rapidly changing health care system. It may be difficult for PHNs to find
knowledgeable or experienced role models in the practice area to teach nurses to
function in their new case manager roles. This study demonstrates that the
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collaborative case management continuing professional education program designed
here between academic and nursing practice successfully improved PHNs’ learning
and performance outcomes. This indicates that future education programs for PHNs
should be established as collaborative programs. This will facilitate the linking
between evidence, learning theories and clinical practice.
The proposed integrated theoretical framework would clearly be useful to
evaluate the quality of other educational programs and offers clear guidance for the
development, delivery and evaluation of educational programs. It ensures significant
effects at three levels of outcomes of an educational program. Careful assessment of
learning factors and effective training and organisational factors contributed to the
success of the PHNs’ learning process. Thus a thorough needs assessment should be
done prior to the implementation of any education program, and future CPE
programs could use relevant learning theories to ensure that the nurses engage with
both the content and process of learning. Four main activities integrated into the
program offered interesting and effective ways to learn about case management,
leading to successful achievement of the anticipated outcomes. Thus using a
systematic framework for educational programs ensures their value and creates
satisfactory benefits and outcomes.
The use of mixed evaluation methods to assess the effects of an education
program should ensure comprehensive information is available to determine the
programs’ effectiveness. Focus groups are an efficient method to assess learners’
needs and identify the initial strategies to fit their educational needs and enhance
their learning processes and outcomes. Focus groups following educational programs
are also important to identify changes in participant practice.
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Future CPE programs should carefully consider the timing and location of the
program so that nurses are able to attend with minimal disruption to their workplace.
This will enhance attendance and allow them to concentrate and apply what they
have learned in the program to their daily practice without being distracted by work
demands.
8.6.2 Implications for Practice
The gaps in case management practice for Taiwanese PHNs were identified
in this study. In relation to current case management practice, three categories were
identified from the focus group discussions, namely ‘educating’, ‘management
activities’, and ‘working with others’. The public health nurses provided health
education and conducted assessing, implementing, monitoring, and following up for
their cases. Usually, the PHNs were required to work with social workers, families
and organisations. Although the PHNs performed case management skills and case
manager role activities at a moderate frequency, they only partially used the case
management process and their case management practice lacked theoretical guidance.
They did not include activities such as case identification of high-risk cases,
identification of available resources and evaluation the outcomes of case
management. In order to enhance case management practice and improve practice
quality, these practice activities need to be further addressed by subsequent studies,
which should also focus on developing a case management model for specific client
populations. The PHNs in the focus groups stated that they had no case management
model specifically designed for care for older adults living alone and mentally ill
patients in the community in Taiwan. Selecting a suitable case management model
and developing case management protocols for different populations serviced by
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nurses in different settings should result in the provision of quality case management
services.
Current gaps in case management practice were identified in this study by
PHNs in two health care centres through the use of two focus groups, and thus may
limit generalisability of these findings. Hence, a national survey for current case
management practice for PHNs may be necessary in order to clearly understand the
current practical situation in case management. Additionally, the development of
standard case management practice protocols is recommended as a possible strategy
to ensure theory-based and qualified case management practice.
8.6.3 Implications for Research
Further research is needed in order to replicate the findings of this study and
to validate the results. An experimental research design with pre- and post-tests was
used here to evaluate the educational program, and the effectiveness of the program
was demonstrated at three different levels of outcomes. The rigorous research design
used in the study thus provided valuable evidence for the positive effect of the
CCMCPE program and its contribution to current knowledge in the area of
evaluation studies. However, the evaluation study was conducted for public health
nurses located in a single city which has particular health care systems and case
management practice, therefore the results may not be able to be generalised for all
continuing education programs for PHNs. It is recognised that the participants may
not be representative of all public health nurses from other areas. Hence, future work
is needed to determine the effectiveness of case management education programs for
PHNs in other areas or with other nursing populations working in a case management
role.
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Additionally, the Chinese-translated instruments used in this study could be
further retested for validity and reliability for PHNs in other areas or other nurse
populations in Taiwan. The reliability and validity of the Case Management
Knowledge Index, Case Management Skills and Case Manager Role Activity Scale
were tested in this study. These same tools could be used or tested in other
populations or used to evaluate outcomes for other research in the field.
Further research is needed to consider ways to reduce possible bias from the
researcher/facilitator role and thus reduce the threat to internal validity. Although the
study used strategies to reduce the potential bias arising from the dual role of the
researcher, this may to some degree have influenced participants’ responses in focus
group discussions, due to social desirability bias. Hence, a study established and
evaluated by a person who is not delivering the course content is ideal, and may
reduce the potential bias introduced by a dual-role facilitator/researcher.
Research is also needed to consider ways to reduce bias from the potential
attention effect and Hawthorne effect. Although the study used strategies to blind the
participants to the intent of the experimental study, some PHNs might still have
known they had been allocated to an experimental group or comparison group. The
researcher attempted to ensure that those PHNs in both the comparison and
experimental groups received the same information, so that both groups would have
similar expectations. However, the potential Hawthorne effect may have occurred
and thus threatened the internal validity of the study. In addition, this program may
not be usual, in that PHNs rarely attend a course from a nursing academic at their
workplace. Thus inevitably the PHNs might pay more attention in this context.
Hence further work is required to develop possible strategies to reduce attention bias
and to blind participants to the educational intervention.
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8.7 RECOMMENDATIONS FOR FURTHER WORK
On the basis of the strengths and limitations of the current study, the
following suggestions for further research and education in relation to preparation for
case management practice for nurses can be made.
1. Conduct a national survey to understand current case management practices
applied in Taiwan.
2. Conduct a CCMCPE program with other nursing populations or with nurses
working in settings different from the current study.
3. Conduct a similar study to the one described here, but using a randomised
control trial experiment where both participants and investigators are blinded to
the group they are in/working with, in order to further evaluate this CCMCPE
program.
4. Use the proposed integrated program framework to guide the development,
delivery and evaluation of other educational programs for PHNs.
5. Use focus groups as a cost-effective means of needs assessment before planning
an educational program.
6. Consider appropriate times and locations when planning to conduct continuing
education programs.
7. Measure the long term impact of this particular CCMCPE on PHNs’ case
management practices.
8. Measure four levels of outcomes of the current CCMCPE program, including the
impact of the CCMCPE on patient outcomes.
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8.8 CONCLUSION
The purpose of this study was to develop, implement, and evaluate a
collaborative case management continuing professional education program for
Taiwanese public health nurses. This study used an integrated theoretical framework
and evaluated three levels of outcomes, including knowledge, skills and practice
changes in relation to case management. Based on the inferential statistics
undertaken on the pre-test and post-test measures, which were gathered by
instruments with appropriate psychometric properties, the educational intervention
resulted in a statistically significant increase in the scores of the PHNs in all outcome
variables. Therefore, all hypotheses were confirmed, as the collaborative educational
program significantly improved PHNs’ knowledge, performance confidence in skills,
preparedness for role activities, frequency of using skills and role activities and case
management practice.
In conclusion, the collaborative case management continuing professional
education program designed and implemented in the current study has been
demonstrated to improve PHNs’ knowledge and understanding of case management
across three levels of outcomes: satisfaction, learning and performance outcomes. It
is clear that a successful program needs to close the theory–practice gap related to
case management, must be implemented collaboratively between nursing academics
and nursing practitioners to meet the rapid changes of this employment climate, and
must meet the complex and diverse contexts currently available in the health care
setting. The collaborative education program in this study was guided by an
integrated theoretical framework in order to guide the development, implementation
and evaluation.
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During this study mixed evaluation methods, as incorporated within an
experimental design, generated a rich data set, which allowed the researcher to
comprehensively demonstrate the effectiveness of the program at multiple levels of
outcomes. The future of the evaluation of CPEs can benefit from the knowledge
gained from this study, in order to better design, develop and evaluate CPE
programs. In this way this study significantly contributes to the literature in the field
by bridging the gaps in prior studies, and also contributes to current knowledge in the
effectiveness and evaluation of CPE programs in the case management field by using
a rigorous research design. The CCMCPE program itself offers an evidence-based
education experience for PHNs and nursing education, extending not only nurses’
knowledge, but also practice, and can be applied in a variety of important healthcare
environments and contexts.
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APPENDICES
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Appendix 1.1 Queensland University of Technology
Centre for Health Research-Nursing
Participant Information Sheet for Public Health Nurses
“Effectiveness of a collaborative case management education program for Taiwanese Public Health Nurses”
Researcher: Wen-I Liu
Phone Number: (02) 28802526 E-mail: [email protected]
5F, 226, Jil-Her Road Shil-Lin 111, Taipei, Taiwan, R.O.C. Description This project is being undertaken one component of a PhD at Queensland University of Technology (QUT) project for Wen-I Liu, a lecturer of National Taipei College of Nursing, under the guidance of an academic staff member, Prof. Helen Edwards. The purpose of this project is to improve Taiwanese public health nurses’ preparation for acting in a case management role. The research team requests your assistance in identifying the effectiveness of a new program. Your health centre has agreed to be involved in this study and I am now inviting you to participate. Participation Your participation will involve completing a questionnaire. Your involvement will last for about two months and the project will be conducted in your workplace. Prior to commencing the study, please read this information package which explains the study and then decide if you wish to provide written consent to the investigator. If you agree to participate in this study, your health centre will either be allocated to a pilot study, a priority course, or a later course. In addition, small discussion group will be held before and after the program. 1. Pilot study group If you are allocated to the pilot study you will fill in the questionnaires and attend the first section of a case management education program. After this step, you will be invited to comment on the questionnaires, program delivery and the program delivery methods. You will have the opportunity to attend the remaining sections of the program after the study is completed. Two focus groups will also take place to discuss case management concepts and your case management education needs if you are in the pilot study groups. There will be 6 to 12 public health nurses in each focus group discussion taking place at the two health service centres. The discussion will be tape recorded, and the conclusions of the group discussions will be verified by the participants. 2. Priority course group If you are allocated to the priority group you will attend the case management continuing education program from approximately the middle of October to December, 2005. This 16-hour program will be conducted for four hours, once every two weeks, for eight weeks in total at your work place. You will attend the program during work time. Before and after the education program you will be asked to complete questionnaires about case management. Note that there are no right or wrong answers to the questionnaires. There will also be a focus group held following the completion of the program. The focus group will evaluate the education program. There will be 6 to 12 public health nurses participating in the focus group discussions. If you are interested in participating in the group discussion, you can contact me and you will be informed individually about the time and place of the group discussion. The discussion will be tape recorded, and the conclusions of the group discussions will be verified by the participants. 3. Later course group If you are allocated to the later course group you will attend the case management continuing
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education program from December to January. This 16-hour program will be conducted for four hours, once every two weeks, for eight weeks in total at your workplace. You will attend the program during work time. Before the education program you will be asked to fill in questionnaires twice (approximately October and December) about case management. Note that there are no right or wrong answers to the questionnaires. Expected benefits It is expected that this project will benefit your case management practice. Risks There are no risks associated with your participation in this project. The education program will require your attendance for eight weeks, with four hour sessions once every two weeks. You should not experience any physical or emotional discomfort during the program. You will need to spend some time completing the questionnaires but it should take you no more than 20 minutes. If you participate in the focus group, it will take approximately 1.5 hours of your time. All these activities will be undertaken during work time. Confidentiality All comments and responses are anonymous and will be treated confidentially. The names of individual persons are not required in any of the responses. Your responses will only be available to the investigators. When the results of the study are published, no person or group will be identifiable. The focus groups will be tape recorded but no names will be used during the discussion and only the researcher will have access to the tapes. All information will be kept in a locked filing cabinet with the School of Nursing, Queensland University of Technology, and only the researcher will have access to that information. Voluntary participation Your participation in this project is voluntary. If you do agree to participate, you can withdraw from participation at any time during the project without comment or penalty. Your decision to participate will in no way impact on your current or future relationship with QUT or the National Taipei College of Nursing. Questions / further information Please contact the researcher, Wen-I Liu (phone: 28802526), if you require further information about the project, or to have any questions answered. If at any time you are not satisfied with the response, you may direct your inquiries to Prof. Helen Edwards (Head of School of Nursing, Queensland University of Technology, Australia; 61-7-38643844; email: [email protected]). Concerns / complaints If you have any concerns in relation to the ethical conduct of this project you may contact the Research Ethics Officer on 61-7-3864 2340 or [email protected]. Acknowledgment Thank you for considering participating in this study. Your help is greatly appreciated. Please ensure that you have read and understood the previous information. If you wish to participate in this study, please sign the consent form and pass it to the researcher. Once again, thank you!
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Appendix 1.2
Queensland University of Technology
Centre for Health Research-Nursing
CONSENT FORM
“Effectiveness of a collaborative case management education program for Taiwanese Public Health Nurses”
Researcher: Wen-I Liu Phone Number: (02) 28802526
E-mail: [email protected] 5F, 226, Jil-Her Road Shil-Lin 111, Taipei, Taiwan, R.O.C.
Statement of consent By signing below, you are indicating that you: • have read and understood the information sheet about this project; • have had any questions answered to your satisfaction; • understand that if you have any additional questions you can contact the
research team; • understand that you are free to withdraw at any time, without comment or
penalty; • understand that you can contact the research team if you have any questions
about the project, or the Research Ethics Officer on 3864 2340 or [email protected] if you have concerns about the ethical conduct of the project;
• agree to participate in the project. Name Signature Date / /
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Appendix 1.3
Queensland University of Technology
Invitation letter Dear Public Health Nurse Colleagues: I am a PhD candidate at the School of Nursing at Queensland University of Technology in Australia and a lecturer at the National Taipei College of Nursing. For my research project I will be conducting a case management continuing professional education program in Taipei City. I would like to invite you to participate in the study. Taipei City is the first city in Taiwan to use case management as a strategy to care for patients with mental illness and older adults living alone in the community. However, there is no academic case management education program in place, and few continuing education programs offered to prepare nurses to be case managers. In order to support and help nurses to acquire needed knowledge and skills to act as nurse case managers to meet workplace demands, I have developed an education program. This 16-hour program will be conducted for four hours, once every two weeks, for eight weeks in total at your workplace during work time. After finishing the program you will be better able to meet your work requirements related to case management. Learning materials will be provided including new case management knowledge, class materials and useful references (all in Chinese). If you agree to participate in the study, you will be asked to provide your written consent. You will be randomly assigned to either a pilot study group, a priority course group, or a later course group, but all participants will have the opportunity to attend the program. If you have any questions about this program, please do not hesitate to contact me and I will answer your questions. Wen-I Liu My contact number is: 02-28802526 (Home) 0952006016 (Mobile) Or you can e-mail to me: [email protected]
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Appendix 1.4
Directions for completing the questionnaire Directions
1. The aim of this questionnaire is to explore your current practice related to case
management.
2. It asks for your general understanding and experiences regarding case
management.
3. All answers will be treated confidentially and your individual answers will not
be shared with anyone.
4. Please answer every question by marking the answer as indicated.
5. There are no right or wrong answers. If you are unsure how to answer a
question please give the best answer you can.
6. After you have completed the questionnaire please place it in the envelope
supplied and return it to the researcher.
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Appendix 2.1
Focus Group Discussion Guide (before pre-tests)
1. Introduction
(1) Welcome participants (2) Introduce the moderator (3) Overview of the background of the study (4) Describe reasons for discussions (5) Set up the general ground rules for the session Ground rules (1) 60-90 minutes (tape recorded—observer and note taker) (2) Speak clearly/ one at a time (3) Conversation/ all participate (4) No right/ wrong answers (5) Assurance of anonymity and confidentiality
2. General concepts about case management
(1) Can you talk about what you know about case management? (2) Can you talk about what the functions of case managers are?
3. Current case management practice
(1) Can you talk about the activities that you perform in your current practice?
(2) Can you talk about how you practice case management? 4. Educational needs
(1) Do you think there is a need for case management education programs? (2) What should a case management education program contain? (3) What learning methods do you think would be more effective in learning
about case management? And what are your preferred learning methods? 5. Summary and confirm the key ideas shared
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Appendix 2.2
Focus Group Discussion Guide (after post-tests)
1. Introduction
(1) Welcome participants (2) Introduce the moderator (3) Overview of the background of the study (4) Describe reasons for discussions (5) Set up the general ground rules for the session Ground rules (1) 60-90 minutes (tape recorded—observer and note taker) (2) Speak clearly/ one at a time (3) Conversation/ all participate (4) No right/ wrong answers (5) Assurance of anonymity and confidentiality
2. General concepts about case management
(1) Can you talk about what case management is? (2) Can you talk about what the functions of case managers are?
3. Current case management practice
(1) Can you talk about the activities that you perform in your current practice? (2) Can you talk about how you practice case management?
4. Evaluation impact on practice (for experimental group)
(1) Did the program affect your case management practice? If yes, can you tell me how the program has affected your practice regarding CM? If not, can you tell me what factors blocked the case management practice changes?
5. General evaluation of case management continuing education program
(1) How would you evaluate this case management continuing professional education program?
(2) Do you have any suggestions about the education program?
6. Summary and confirm the key ideas shared
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Appendix 2.3
Transcript of focus group discussions (before intervention) The focus group before the educational program - District A
Participants’ Reactions Moderator’s Reactions Analysis Nurse 1: In principle, case management is to list cases and manage clients, such that certain arrangements are made for abnormal cases. Nurse 2: We observe his or her (the client’s) knowledge, attitudes, behaviors, and cognitions toward his or her food habits, look at any abnormalities, and place emphasis on the management of cases such as hypertension, heart disease, and high blood-lipids. Nurse 3: If the patient has these problems, he can contact us, and by having an overall understanding of his living condition, knowledge and attitudes, living activities, and familial interactions, we can see if there are things that we can help him with. This is what we place our emphasis on. (Other nurses were silent) Nurse 4: In addition, we care for all the older adults living alone and all the mentally ill patients in our responsible area. We are not familiar with how to care mentally ill patients as it is a new task for us since 2005, but yet we need to care for all the psychiatric patients in the community. It’s quite difficult for us. Nurse 2: In principle, we need to provide him (the client) with some knowledge for him. Many cases have incorrect concepts, and we need to constantly give them the correct ones. This is
I (the teacher) would like to find out what you understand about case management. Anything else? Next, I would like to understand the extent of your case management practice.
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where the emphasis of case management is. Follow-up management is required if patients are transferred to other hospitals. Nurse 5: Case management also includes components that we are less capable of addressing ourselves, such as helping solitary seniors. We can work then with social workers or other organisations to help families and individuals in these situations.
Nurse 5: Yes. Nurse 6: To my understanding, case management in hospitals is a little different. Case management in hospitals focuses on specific diseases, whereas we cover all categories of illness. I often look up information in those areas that I am less familiar with. So I have no idea what case management really is. It is somewhat different from the one in hospitals. Some resources cannot be easily referred. This is a problem. Nurse 7: I think that clinical case management is different from the case management that we do. We look at things from a long-term perspective and focus on health promotion and prevention. It’s harder for us to see short-term results. Nurses 2: The “3 Highs” (high blood sugar, high blood-lipid, and high blood pressure), heart disease, cancer, and other chronic diseases. Also older
Do you mean that case management includes referrals? Hmm. So it also includes searching for other resources for cases? So the main point you mentioned is “health promotion and prevention.” Under the current administrative body, what kinds of cases definitely require management?
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adults living alone and mentally ill patients. Nurse 8: The cases need to be either in the “3 Highs” category or be heart disease related. Because of the performance review, we can only take care of these patients. There is so much work, so we spend less time on case management. Nurse 1: Regulation of abnormal case management. Nurses 2: The “3 Highs” (high blood sugar, high blood-lipid, and high blood pressure) and other chronic diseases. Also older adults living alone and mentally ill patients. Nurse 5: Recently we have introduced a standard procedure of management. Nurse 3: We visit the cases and measure their blood pressure and cholesterol levels…etc, and invite them to participate in our seminars or activities involved in health promotion. We also see if there are sources that allow referrals for the cases. Nurse 2: I wonder if (you) could teach us effective case management. In fact, we have no idea what case management is really about. We have not learned about case management before, so we do not understand the core and concepts of case management.
Is there a priority? What is the case management that you currently work on? What does abnormal mean? What are the follow-up regulations? What kind of things regarding case management do you feel should be added in the current course?
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Nurse 1: Yes, we do not have a clear understanding of case management. We just use trial and error to conduct case management. Other Nurses: Yes, we do not understand case management much because we did not have training in this field. Nurse 6: Our actual practices seem to be somewhat different from the theoretical framework of case management. Nurse 2: We have a “public health information system” that contains the information about the cases. It includes all the information about case acceptance, such as the information input after visiting the cases. Nurse 7: Yes! It’s just that I wonder whether these things are the same as the system in the curriculum that you teach. Nurse 6: Aren’t there many types of disciplines in the model of case management that you teach? Nurse 1: In principle, it depends on how the teacher leads the course, and we’ll see what improvements are needed
So it sounds to me as if you do not have a clear understanding of case management.
So it seems like a prototype of standardization is actually emerging. I will focus on the basic concepts and processes and we can work together to make them fit with your current situation. Is there any other teaching method that you think will be effective?
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during the process. Nurse 2: It’s better to just make the modifications during the classes. Nurse 6: It’s better to be interesting and effective and to ensure we can apply it to our current practice. Other nurses: Yes. All nurses: Yes, thank you very much!
Do you have any other comments? Alright. What I can think of now is to use a more relaxing way to show you how much you know. I’ll then teach you new knowledge, and then we will apply the theories to your work. I will ask you in each class what modifications to the teaching are required, and I will do them right away.
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Appendix 2.3
Transcript of focus group discussions (before intervention) The focus group before the educational program - District B
Participants’ Reactions Moderator’s Reactions Analysis
Nurse 1: What kind of definitions do you have of case management?
Nurse 2: Each of us has an area and we are assigned to different areas. We do case acceptance management for some special cases in our own areas. Nurse 2: High blood sugar, high blood-lipid, high blood pressure, and chronic diseases. Also, we need to manage older adults living alone and mentally ill patients. Nurse 3: Health education, seminars, and screenings…etc. Nurse 4: It is mainly about evaluating people’s health issues. Majority of the nurses: Yes. Nurse 5: Actually, our station has a framework in
I (the teacher) would like to find out what you understand about case management. I would just like to understand what your cognitions are about case management. Hmm. So it’s the case acceptance management of abnormal cases?
What are special cases? So what are your actual practices in terms of case management?
How about the rest of you? What are the specific activities that you do when conducting case management? Such as doing certain things for certain cases in terms of case management.
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which 70 to 80 cases are accepted for each sector (of an area). Most of the targets of case management are cases of hypertension, high blood-pressure, and high blood-lipid. Also, we need to care for all the older adults living alone and all the psychiatric patients in our areas. For these cases, we conduct one home visit about every two months in order to do things like understand if these clients are taking medication regularly and providing common screenings and health education. These are known as “caring visitations.” Nurse 3: Nothing in particular. We just encourage them to participate in some activities such as group health seminars. Nurse 2: We are probably ok. (Other nurses shake their heads) It’s just that case management is 1/10th of our tasks. Not everyone does case management.
Nurse 4: I do not have a clear understanding of my role in case management. (Other nurses nod) Nurse 2: The tasks of “health promotion teams” take up a lot of time. As for “case management teams,” they do not only need to handle matters regarding case management, but also need to hold many seminars.
Nurse 3: Health promotion and case management are not clearly separated for us. The tasks are scattered.
Are you clear with the role that the nursing staff plays?
How about others? Isn’t it true that “case management teams” and “health promotion teams” are separated since January 1st 2005? Are they taking up most of your time?
I believe some nurses conduct home visiting in the afternoon and they take a lot of time to do case management.
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Nurse 2: Sometimes we even can’t do home visiting for a week. Nurse 2: Yes, it’s still useful! Nurse 5: Yes, of course. For me, I have not had any training in case management. I think it is very necessary! (Majority of the nurses nod) Nurse 3: Actually, “health promotion” also wants us to handle “case management” well. However, some of the tasks in health management are not left out. We are already having trouble completing our given assignments, and we really don’t have too much time to take care of case management. Majority of the nurses: Hmm. Nurse 5: Actually, for the curriculum that you have, please teach us the complete set as we want to learn all of the content.
Majority of the nurses: Hmm, Yes. Nurse 7: Yes! Because we are not very clear about what case management is and what the case management concepts and frameworks are.
Nurse 8: Basically, we seldom have access to
education and training that would teach us how to perform case management. We hope that the methods used in teaching us about case management can be matched with our experience.
Do you still feel that this course is necessary?
Actually, if Taipei City Government decides to include case management as one of your tasks, it will make people feel that case management is one of your main tasks. It’s seemed to be a practical issue. I can understand your situation. What are your expectations
about the course? I will try my best to teach you
what you need and can use for your actual practice.
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Nurse 5: Because what we learned is what the schools and senior colleagues have taught us. Nurse 8: Yes! Very little. Nurse 6: Yes! They just mention a little bit about case management.
Nurses: Hmm. Nurse 1: Do you mean that do we want to do group discussions, seminars, or presentations?
Nurse 1: I think the teacher should first talk about the basic concepts and frameworks, and then we should add in our experiences from actual practice for discussions. Majority of the nurses: Yes. Majority of the nurses shake their heads. Nurse 1: Ok! We can do that. Majority of the nurses: Yes, ok.
Ok, so all of you want to apply the theories you learn here on the work. Does everyone agree? I want you to first tell me what kind of useful methods you want me to teach you.
Yes, I want to know your preferred learning methods. Anything else? So, you want to establish the
fundamental concepts of case management, and then integrate the actual practice with these concepts. So you are not averse to spending some time on group discussions?
Perhaps I will first use the curriculum that I designed. If it doesn’t go well, we’ll just change it later? So I’ll give you a summary. The curriculum will initially proceed according to the teacher’s design regarding each procedure of case management, tools, what cases need to be closed, and
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Majority of the nurses: Ok, thank you very much!
how to arrange priority. If you have any problem with the flow of the curriculum, I will make changes right away.
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Appendix 2.4
Transcript of focus group discussions (after intervention) The focus group after the educational program
Nursing staff Moderator’s reactions Analysis W: My concept of case management is that it aims to address the needs of a particular case and deal with such needs appropriately. For example, our clinic pays particular attention to patients from minority groups, and after evaluating the needs of each particular case, we link them with community resources, and help them to look for such resources as well as inform them of the community resources that are available to them. W: Yes T: There is a need to search for necessary cases, and then carry out some healthcare protection and resources link-up. It is impossible to do everything alone. Others: Nod their heads in agreement. S: Yes. Prior to the course, we thought that we had to attend to case file where health issues are involved. After the course, we learnt how to sieve through the cases, in order to address the cases that are truly in need of case management.
(Explains the objectives and scope of the meeting.) Hi everyone, I am Lecturer Liu Wenyi. I would like to know more about your understanding of case management. I hope that everyone will freely express themselves. In other words, after evaluating the client’s needs, the follow-up primarily involves connecting them to the available resources. Is this concept shared by others as well? Did your concept of case management change after attending the course? Thus you realise that not all the cases need to be handled. In other words, does it mean that everyone now has the concept that cases need to be screened? You mean that current operational policies do not allow
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All: Nod their heads in agreement. H: However, the health industry currently still focuses on the quantitative targets for case management, which may not be possible to meet if we put what we have learnt into practice. H : Right. We know the importance of screening through the cases, but we need to look at the quantitative targets and achieve these targets. All: Nod their heads in agreement T : Also, after the course, we learnt that data from a medical examination cannot be used as an indicator for accepting a case. For example, for some sicknesses such as hypertension, there will still be anomalies in the blood pressure from time to time. Therefore, when we observe some anomalies in the medical examination data, we will continue to consider the other needs of the case. We will accept the case only if there are multiple needs. This is an improvement in our conceptual thinking. All: Yes, we understand. All: Hmm.
you to actually carry out case screening? In other words, you understand what is required conceptually, but in practice there are limitations due to administrative policies? Does everyone understand what she is trying to say? It is necessary to see if there are multiple needs in the case, and it must be thoroughly considered whether a case really needs case management before it is accepted.
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W: Home visits are only a small part of case management. C: Screening cases before accepting them, collecting information to evaluate the status of the case and then looking at the client’s needs, such that cases with multiple needs will be accepted. Collection of information can be done through direct house visitations, in order to draw up a health plan to determine the needs. After that you need to carry out the necessary link-ups to the available resources, and find out which units or organisations are willing to participate and help. Finally, it is necessary to monitor and evaluate the services in the course of the case management, in order to determine whether the services should continue or be terminated as a result of the goals having been achieved. W: There is also a coordination aspect. We need to carry out coordination work on their behalf. All: Agree. All: Agree. The concept is more complete now.
Anything else?? Could you express the concept of case management? Don’t worry, this is not an examination, but I merely wish to understand the current concept of case management that you have. Collecting information, discovering the problems and needs, linking up resources, monitoring and evaluation have already been mentioned. Is there anything else? Therefore in practice, a more comprehensive concept would be the entire process that was outlined by W. Before attending the course, everyone would say that case management is about house visitation and file classification, but in reality these are only small aspects of case management. Thus a complete concept of case management would be the complete service process. What do you think your roles are? What are the roles of case management staff?
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C: Screening the cases that require case management. H : Coordinator. In the past, I used to think that case management had to be completed by myself, but I now realise that case management can be carried out effectively only through interaction and cooperation with other units. W: There is also the role of cooperation. S : Right. Some cases cannot be handled alone. Cooperation is required with other medical units. All: Hmm. T: Communicator, coordinator, partner, link-up person etc. C: There is also the aspect of directly providing services. All: No. T: There will be medical instructions that will be given if anomalies are seen in the medical examination. S: Screening cases and measuring blood pressure etc. Y: For example we have encountered diabetic patients who are afraid of gripping their fingers for fear of pain, so we will look for other ways to help them. Y: Hmm. For example, the needs of some cases are not restricted to health
The roles of screening and linking up have been mentioned; is there anything else? Good. Is there anything else? I have just discussed about the roles. Is there anything that anyone would like to add? Next I would like all of you to describe the actual contents of your current case management work. In other words, what are the case management activities that you are actually carrying out at the moment? I am referring to the aspect of case management. Do you mean that you will give different treatments to different cases based on the specific needs of the cases?
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problems. Some require the help of other units. We have already learnt how to search for those resources which can help, for example charitable resources. We have also learnt how to communicate and listen to the patients in our cases. Y: Hmm. S: After identifying the case problems, I go directly into the service aspects, as well as link-up with resources. Currently the direct services aspect is gradually being reduced, while the link-up with resources has been increased. S: Yes, but not too much time is involved. In the area of case planning, our focus is relatively less. C: After identifying the problems of the client, we are directly informed as to how the case is to be handled. W: There is relatively less discussion about the cases. C : For illnesses of an immediate nature, we will directly connect with medical units or look for volunteers to help out. We will then contact the family members. H : For the long term aspects, we will rely on the help that is given by other units. H: No. C: No. W (Zhaorong): In reality, for the planning aspect, we do not usually write down our case evaluation, plans and execution. However, we still follow the case management process.
Thus you make use of some community resources, and focus on the area of link-ups? And you have also learnt about case communication? What other case management activities are there? From the case management process that we have just discussed, does your actual work follow such a process? You mean that case management is time-oriented, and a case will be handled immediately after the problem is discovered? Thus you mean that after determining the problems of the case, you do not usually set long term objectives? Thus you already know how to
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All: Hmm. W: My personal intuition related to medical problems is relatively good, and I can tell where the case problem lies. All: Hmm. T (Mingyu): Actually I feel that I have learnt the screening technique. We will not always rely on the administrative target as a guide when accepting cases. We will evaluate the needs of the cases from a wider variety of angles. C : In the past we tended to accept all cases that had medical anomalies or cases that are transferred to us, but we do not do this nowadays. We now know that we need to focus more on the qualitative aspects of case management rather than the quantitative aspects. All: Hmm S: Currently, the real change is in my philosophy and concept of case management. W: Nowadays we put more emphasis on qualitative assessment, and we are also more aware as to how to explain what we are doing. W : Hmm.
use the case management process, but it is only that it is not complete because of work and time limitations. Hmm. You mean that you have a clearer concept of case management now, and know what to do at the appropriate time. Does that mean that you have better self-judgment and handling abilities? Did you learn any techniques? Hmm. Does it mean that everyone is better at using the screening technique? Did you change the way you handle case management after attending the course? Hmm. Could we say that there are areas that have changed? So, does it mean that the overall concept and focus on the quality of healthcare have changed, and you know how to explain the effectiveness of case management and how to highlight the qualitative objectives? For the rest of you, what areas in case management would you like to change?
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T : The area I wish to change is to identify the characteristics of my speciality and to focus more on expressing the qualitative results. This enables other people to see the concrete results of case management, and to see that it cannot be replaced by other professions. All: Hmm. Right. (Everyone nods in agreement.) T: I will make some changes to the guidelines for accepting cases and terminating cases. L: I will be clearer and more confident about accepting and terminating cases. H: I have also benefited in the area of communication and coordination. I am able to coordinate my role with the case and the roles of other units in a more concrete manner. All: Hmm. (Everyone nods in agreement.) H: Actually, our current workload is really very heavy. There will sometimes also be some temporary duties or duties to handover or temporary problems that require immediate attention. All these issues affect the amount of time that we have for case management. C: For example, the busiest period for health services centres is October, November and December. There are many items to close, evaluations to be
Hmm. Do you mean that you understand that case management is about putting emphasis on the qualitative results and highlighting the qualitative effectiveness of case management? Are there any other changes? There is more confidence in accepting cases and ending cases, and there is also more concrete coordination and communication. Hmm. After attending the course, some changes are being made, but problems can be encountered in the course of making these changes. Could you tell me some of the problems that you have encountered? Hmm.
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made and reports to be filed. Thus it is not that we do not wish to attend the classes. All of us are keen on attending such continuing career education. W: I am in charge of our district. We try our best to arrange our job schedules and coordinate with one another so that we can attend the classes. T: We are divided into case management staff and health facilitation staff. Therefore only one half deals with case management. Our group leader encourages us to attend. If a person is really unable to attend due to work reasons, such a person must apply for leave from the class beforehand. W: The main thing is that our centre supervisor puts a lot of emphasis on case management, and often encourages us to attend further career education courses such as this. H: I suggest that some lecture notes could be given out before the course, so that people can look through them and be attracted to the course. C: Is there such a need? People may not read the notes. It depends on the person; a person who wants to attend the course will arrange his work schedule to come along. W: The course was originally scheduled for July, but it was delayed for a long time. Due to a heavy workload, some nursing staff were unable to attend the course and they feel a sense of regret.
Hmm. I would like to understand some of the reasons for the inability of nursing staff from some regions to attend the course. Hmm. Thanks for your cooperation and participation. Hmm. Hmm. In other words, there are many reasons for nurses’ inability to attend the course. I know that everyone has tried your best to come for the classes. Thank you very much. Next we will discuss your suggestions for the course. Hmm. Thanks for your suggestion. Hmm. Actually it was due to personal reasons that I had to postpone the course to October, near the end of the year. I will take this point into consideration in my future planning. In other words, you mean that arranging some activities or
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S: For example the learning activities organised by the lecturer are very good, very attractive, very interesting, and are relevant to our work. The results are good. W: Right, my colleagues all say it was very lively, and very effective. All: Right. (All nod in agreement.) C : We have benefited very much from attending this course. In the past, there has not been such a comprehensive and systematic course available. W: No. The majority of our colleagues have not attended a case management course. We are very fortunate, thanks to our teacher. All: Right. (All nod in agreement.) L : I suggest that the Health Ministry sends new staff for such courses, because they are very helpful, and we are very fortunate to have attended this course.
discussions of work scenarios will help in the learning process. Hmm. Does anyone have any suggestions? Hmm. Actually I am only playing the role of an educational facilitator to help everyone understand the case management course. I hope that after the conclusion of this course, it would be really helpful to you in the course of your work. Thank you for all your feedback, and for your attendance at today’s post-course evaluation session.
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Appendix 3
Learning manual of the educational program
Case Management Education Program for Public Health Nurses
Facilitator: Wen-I Liu National Taipei College of Nursing
Queensland University of Technology Grant from National Science Council in Taiwan
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Case Management Education Program Program Collaborative Case Management Continuing Professional Education Program Background Public health nurses require preparation for acting in case management roles to
meet the changes in the health care delivery system Participants Public health nurses (PHNs) in health centres of Taipei City Goals 1. Prepare PHNs for case management theory and practice
2. Achieve theory-based guided case management practice Objectives By the end of this 16-hour course, all participants will have:
1. Explored their current understanding of case management 2. Reviewed case management concepts and the management process 3. Practised case management skills in teams 4. Reflected on the differences between current practice and case
management theory 5. Examined their experience and criticised their current practice 6. Developed possible strategies for problem solving in their practice 7. Written planned action activities 8. Actioned planned skills and case manager activities in their workplace
Content 1. Case management concepts and process 2. Case management skills, communication skills and leadership skills 3. Case manager role activities 4. Specific case management practice
Facilitator Wen-I Liu Lecturer of national Taipei College of Nursing; PhD candidate at Queensland University of Technology
Sessions Total of 16 hours, comprising four half-day sessions; one every two weeks; 1:30pm-5:30pm
The Site Teaching rooms at health care centres in Taipei City Learning Strategies and activities
Four types of learning activities: 1. Inductive learning activity - Explore strategy
A learning activity that connects learners with what they already know and with their unique context
2. Input learning activity - Interactive lecture strategy A learning activity that invites learners to examine new input (concepts and skills) - the content of the course
3. Implementation activity - Critical reflection strategy A learning activity that gets learners to do something directly with new content by implementing it.
4. Integration learning activity – Action plan strategy A learning activity that integrates this new learning into their daily work
Evaluation Methods Focus group discussions 1. Case management concepts 2. Current practice in case management 3. Practical changes after the educational intervention Self-reported questionnaires: 1. Knowledge regarding case management 2. Performance confidence in case management skills 3. Frequency of using case management skills 4. Preparedness for case manager role activities 5. Frequency of using case manager role activities
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Learning plans for the educational program over four sessions
Session Course Content Learning Activities Time Frame
Session One (Week One)
Case management concepts 1. Definition of case management 2. Historical perspective of case
management 3. Purposes of case management 4. Case management models
1. Pre-tests 2. Induction activities 3. Input activities 4. Reflection activities 5. Integration and action
activities 6. Evaluation
0.5 hour 0.5 hour 1.0 Hour 1.0 hour 0.5 hour 0.5 hour
Session Two (Week Three)
Case management process and skills: 1. Case selection, skills and role
activities 2. Client assessment, skills and role
activities 3. Case management planning,
skills and role activities 4. Interviewing skills 5. Developing partnership skills
1. Induction activities 2. Input activities 3. Reflection activities 4. Integration and action
activities 5. Evaluation
1 hour 1 hour 1 hour 0.5 hour 0.5 hour
Session Three (Week Five)
Case management process and skills: 1. Implementation, skills and role
activities 2. Monitoring service delivery,
skills and role activities 3. Evaluation, skills and role
activities 4. Coordination skills 5. Negotiation skills
1. Induction activities 2. Input activities 3. Reflection activities 4. Integration and action
activities 5. Evaluation
1 hour 1 hour 1 hour 0.5 hour 0.5 hour
Session Four (Week Seven)
Specific case management practices: 1. Care needs of specific
populations 2. Case management tools 3. Community resources 4. Service referrals 5. Advocacy skills 6. Collaboration skills
1. Induction activities 2. Input activities 3. Reflection activities 4. Integration and action
activities 5. Post tests
0.5 hour 1 hour 1 hour 0.5 hour 0.5 hour
Time: Tuesday, Wednesday and Thursday 1:30-5:30pm Site: Seminar room of each health service centre
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Session One: Case management concepts
Objectives
By the end of this session the learners will have: 1. Examined their current knowledge during the learning activities. 2. Demonstrated updated knowledge of basic concepts of case
management, including definition, history, purposes, and models. 3. Reflected and clarified their concepts and their past experience. 4. Discussed and analysed suitable models to fit the organisational setting.
Content outline
1. Definition of case management 2. Historical perspective of case management 3. Purposes of case management 4. Case management models
Learning models
1. Adult learning in small groups 2. Transformative learning through Critical Reflection and action
Learning Strategies
1. Warm up activities 2. Input activities 3. Implementation activities (Critical reflection) 4. Integration activities (Action at the workplace)
Evaluation strategies
1. Self review of the knowledge and skills learned 2. Self review of the role activities 3. Self examination of the learning objectives 4. Group recheck and confirmation of the items in Activity 1
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Session One: Learning activities and materials Case management concepts
Learning activities and directions
Activity categories Learning activities and directions Time frame
1.1. Warm up activities
1.1.1: Find four people to form a group. Each group receives one set of cards from the facilitator, including 20 questions related to case management. Work with your group to find the answers to these questions.
15 mins
1.1.2: Discuss those concepts that you already know and share them with your group. For example: The purposes of case management are ……
15 mins
1.2 Input activities -Review and questions
1.2.1: Review these descriptions of the definition, history, purposes, and models of case management. Do you have any questions? Please write them down. The facilitator will address them.
20 mins
1.2.2: Circle the concept that is closest to your understanding. Next, we’ll hear a sample of responses.
30 mins
1.3 Implementation activities – Critical reflection
1.3.1: Reflecting on your current practice, define the case management that most closely fit what you are doing. Compare your own definition with the given definition. What are the differences? Share your answers with your group.
15 mins
1.3.2: List three expected case management purposes that you can achieve with your clients. Share your answers with your group.
15 mins
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Activity categories
Learning activities and directions Time frame
1.3 Implementation activities-Critical reflection
1.3.3: After analysing the case management models, select one model which may fit in with your organisation and give reasons. Then write the answers on the white board and we’ll hear the responses from the other groups.
20 mins
1.4 Integrative activities-Action plans
1.4.1: Complete the Table 1.4.1 with definitions, history, purposes and models of CM.
10 mins
1.4.2: Please list ten activities that you perform in your practice. Complete Table 1.4.2.
10 mins
1.4.3: Reviewing your clients for case management services, please list five clients and give the reasons for provision of case management services and the goals associated with those clients. Complete Table 1.4.3.
10 mins
1.5 Evaluation activities
1.5.1: Reviewing your answers in Table 1.4.1, what different concepts have you learned during this session?
15 mins
1.5.2: In your opinion, has this session helped you to learn more about case management? Discussing in your groups, please consider the disadvantages and advantages of this session. Is there anything you would like to see added?
15 mins
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Table 1.4.1. Please complete the table. Concepts Prior concepts Current concepts
Definitions of Case management (CM)
History of CM
Purposes of CM
Models of CM
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Table 1.4.2. Please list ten activities that you perform in your practice. Activity 1
Activity 2
Activity 3
Activity 4
Activity 5
Activity 6
Activity 7
Activity 8
Activity 9
Activity 10
Table 1.4.3. Please list five of your clients and describe the reasons why they require CM services and their goals for CM.
Client Reasons for CM services Expected Goals Client 1
Client 2
Client 3
Client 4
Client 5
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Session Two: Case management process and skills (I) Case selection, Assessment and Planning
Objectives By the end of this session the learners will have: 1. Explored their understanding of case manager role activities through the
steps of case selection, assessment and planning. 2. Demonstrated their understanding of the skills involved in case selection,
assessment and planning. 3. Practiced the skills of interviewing and building up relationships in the
classroom. 4. Examined their experiences and explored and critically assessed their
current practice. 5. Developed strategies for problem solving in their practice. 6. Written planned action activities.
Content outlines 1. Case selection and practical activities 2. Client assessment and practical activities 3. Case management planning and practical activities 4. Skills of interviewing 5. Skills assisting in developing partnerships
Learning models 1. Adult learning in small groups 2. Transformative learning through critical reflection and action
Learning Strategies 1. Warm up activities 2. Input activities - Interactive lecture, role plays 3. Critical reflection through guided group discussion 4. Written action plans
Evaluation methods 1. Self review of the knowledge and skills learned 2. Self review of the role activities 3. Self examination of the learning objectives 4. Group recheck and confirmation of items in Activity 1
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Session Two: Learning activities and materials Case management process and skills (I)
Case selection, Assessment and Planning
Learning activities and directions Activity categories
Learning activities and directions Time frame
2.1. Warm up activities
2.1.1 Find four people and form a group. Each group receives one set of cards from the facilitator, which list 27 role activities. Work with your group to find the activities related to case selection, assessment and planning and put them together.
15 mins
2.1.2 Discuss within your group to confirm the three categories of activities. Then ask the facilitator to check your answers.
15 mins
2.1.3 Review your completed Table 1.4.2. Compare and discuss the answers in this activity with those you wrote earlier. Then we’ll hear a sample of responses when critically examining your current practical activities.
20 mins
2.2 Input activities -Review and questions
2.2.1 Review these descriptions of case selection, assessment, planning of the case management process. Do you have any questions? Please write them down. The facilitator will address them.
30 mins
2.2.2 Review the case example descriptions offered, and discuss with your group some of the skills available to build relationships with clients and to aid successful interviewing. Then we’ll hear a sample of responses.
20 mins
2.3 Implementation activities -Critical reflection
2.3.1 Work with your group to identify the most common five criteria for selecting clients for case management services and give reasons for your choices. Then select a group representative to write your answers on the white board. Criteria 1: Criteria 2: Criteria 3: Criteria 4: Criteria 5:
15 mins
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Activity categories
Learning activities and directions Time frame
2.3 Implementation activities -Critical reflection
2.3.2 Reflect on your past experience and list the most frequent needs and goals for older adults living alone. A representative should then write them on the white board. Then critically examine your current practice about these issues and discuss strategies for improvements.
15 mins
2.3.3 Reflect on your experiences and list the most common problems you experience when you offer case management services to older adults living alone. A representative should then write them on the white board.
20 mins
2.4 Integrative activities - Action plans
2.4.1 Using the case example descriptions provided for conducting role plays, one person should act as a case manager attempting to build a relationship with the client using relevant skills. The remaining group members should take notes or write questions about the process. Then other members can take turns to demonstrate the relevant skills.
20 mins
2.4.2 Please list five role activities that you will conduct in the next two weeks. Complete Table 2.4.2.
10 mins
2.5 Evaluation activities
2.5.1 Complete Table 2.5.1. What different concepts you have learned in this session?
15 mins
2.5.2 In your opinion, has this session helped you to learn more about case management? Discussing with your group, please consider the disadvantages and advantages of this session. Is there anything you would like to see added?
15mins
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Table 2.4.2. Actions Who By when Check
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Table 2.5.1. Please complete the table. Concepts Prior concepts Current concepts
Case selection and practical activities
Assessment and practical activities
Planning and practical activities
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Session Three: Case management process and skills (II)- implementation, monitoring and evaluation
Objectives
By the end of this session the learner will have: 1. Explored their understanding about case manager role activities through
the steps of implementation, monitoring and evaluation. 2. Demonstrated their understanding of the case manager role activities
through the steps of implementation, monitoring and evaluation. 3. Practiced skills of coordination and negotiation in the classroom. 4. Examined their experiences and critically examined their current
practice. 5. Developed strategies for problem solving in their practice. 6. Written planned action activities.
Content outlines - Case management process and skills 1. Implementation, coordination and practical activities 2. Monitoring service delivery and practical activities 3. Evaluation and practical activities 4. Coordination skills 5. Negotiation skills
Learning models 1. Adult learning in small groups 2. Transformative learning through critical reflection and action
Learning Strategies 1. Warm up activities 2. Input activities - Interactive lecture, role plays 3. Critical reflection through guided group discussions 4. Written action plans
Evaluation methods 1. Self review knowledge and skills learned 2. Self review the role activities 3. Self examine learning objectives 4. Group recheck and confirm items in Activity 1
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Session Three: learning activities and materials Case management process and skills (II)-
implementation, monitoring and evaluation Learning activities and directions
Activity categories
Learning activities and directions Time frame
3.1. Warm up activities
3.1.1 Find four people to form a group. Each group receives one set of cards from the facilitator which list 27 role activities. Work with your group to find the activities related to implementation, monitoring and evaluation and put them together.
15 mins
3.1.2 Discuss within your group to confirm the three categories of activities. Then ask the facilitator to check your answers.
15 mins
3.1.3 Review your answers to Table 1.4.2, and compare and discuss these activities with those you wrote earlier. Then we’ll hear a sample of responses in order to critically examine your current practice activities.
20 mins
3.2 Input activities -Review and questions
3.2.1 Review these descriptions of implementation, monitoring and evaluation of the case management process. Do you have any questions? Please write them down. The facilitator will then answer your questions.
30 mins
3.2.2 Reviewing the offered materials, please discuss your experiences in coordination and negotiation with your group. Then we’ll hear a sample of responses.
20 mins
3.3 Implementation activities -Critical reflection
3.3.1 Work with your group to identify the three most common problems when offering case management services for older adults living alone and give reasons for your responses. A representative should write them on the white board. The facilitator will then lead the group discussions. Problem 1: Problem 2: Problem 3:
20 mins
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Activity categories
Learning activities and directions Time frame
3.3 Implementation activities -Critical reflection
3.3.2 Reflecting on your past experience, do you measure any outcomes of case management for the older adults living alone? Do you think it is necessary to measure outcomes of case management? If yes, please list the outcomes you need to assess. If no, please give your reasons. A group representative should write these answers on the white board.
30 mins
3.4 Integrative activities - Action plans
3.4.1 Using the case descriptions provided for conducting role plays, one person should act as a case manager while another acts as a social worker while discussing needed services for your client. The remaining group members should take notes or write questions about the process.
20 mins
3.4.2 Please list five role activities that you will conduct in the next two weeks. Complete Table 3.4.2.
10 mins
3.5 Evaluation activities
3.5.1 Complete Table 3.5.1. What different concepts have you learned in this session?
15 mins
3.5.2 In your opinion, has this session helped you to learn more about case management? Discussing within your groups, please consider the disadvantages and advantages of this session. Is there anything you would like to see added?
15mins
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Table 3.4.2 Actions Who By when Check
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Session Four: Specific case management practices Community case management for mentally ill patients
Objectives
By then end of this session the learners will have: 1. Explored their understanding of the needs and goals for community-
based mentally ill patients. 2. Demonstrated their understanding of the available community resources
for community-based mentally ill patients. 3. Practiced the skills of collaboration and advocacy in the classroom. 4. Examined their experiences and criticised their current practice of
community case management for mentally ill patients. 5. Developed strategies for problem solving in their practice of community-
based case management for mentally ill patients. 6. Conducted case manager role activities within their daily practice.
Content outlines 1. Care needs of specific populations 2. Case management tools 3. Community resources and service referrals 4. Advocacy skills 5. Collaboration skills
Learning models 1. Adult learning in small groups 2. Transformative learning through critical reflection and action
Learning Strategies 1. Warm up activities 2. Input activities - Interactive lecture, role plays 3. Critical reflection through guided group discussions 4. Written action plans
Evaluation methods 1. Self review knowledge and skills learned 2. Self review the role activities 3. Self examine learning objectives 4. Group recheck and confirm items in Activity 1
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Session Four: Learning activities and materials
Community case management for mentally ill patients
Learning activities and directions Activity categories
Learning activities and directions Time frame
4.1. Warm up activities
4.1.1 Find four people to form a group. Each group receives one set of cards from the facilitator, which list care needs for mentally ill patients. Work within your group to find the five most frequent needs for this population. Then ask the facilitator to check your answers.
15 mins
4.1.2 Discuss within your group to establish five goals for the five needs according to the results of 4.1.1. A representative should then write them on the white board.
15 mins
4.2 Input activities-Review and questions
4.2.1 Review these descriptions of community case management for mentally ill patients. Do you have any questions? Please write them down and the facilitator will answer your questions.
30 mins
4.2.2 According to the descriptions of the case study offered, work with your group to answer the following questions: 1. Does the case need case management services?
Please give reasons. 2. Please list the care needs for the case. 3. Please set the goals for case management
services. 4. Please list available community resources for the
case. A representative should write them on the white board. Then the facilitator will lead a discussion about the answers.
20 mins
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Activity categories
Learning activities and directions Time frame
4.3 Implementation activities-Critical reflection
4.3.1 Work with your group to identify the three most common problems that occur when offering case management services to older adults living alone and give reasons. Then a representative should writes them on the white board. The facilitator will lead a discussion. Problem 1: Reasons: Problem 2: Reasons: Problem 3: Reasons:
20 mins
4.3.2 Reflect on your past experiences. Do you measure any outcomes of case management for mentally ill patients? Do you think it is necessary to measure outcomes of case management? If yes, please list the outcomes you should assess for mentally ill patients. If no, please give your reasons. Then a representative should write them on the white board.
30 mins
4.4 Integrative activities-Action plans
4.4.1 Reflecting on your experiences, give an example to describe how you conducted advocacy for a mentally ill client. Please critically examine the skills used. The remaining group members should provide comments on the example.
15 mins
4.4.2 Reflecting on your experiences, give an example to describe how you collaborated with other service providers a mentally ill client. Please critically examine the skills used and list three possible improvements for this example.
15 mins
4.5 Evaluation activities
4.5.1 Please complete the offered questionnaire.
20 mins
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4.5.2 In your opinion, have these four sessions helped you to learn more about case management? Were there any practice changes following the program? What factors have influenced your changes? Do you have any suggestions for this program?
15mins
316
Table 4.4.2 Actions Who By when Check
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Appendix 4.1
Expert panel evaluation sheet Please circle the ONE response that corresponds to your best answer. 1: Disagreement 2: Partial agreement 3: Total agreement 1. Is the course content required for public health nurses? 1 2 3 Comments: 2. Are the goals and objectives clear and defined? 1 2 3 Comments: 3. Can the course design achieve the expected goals and objectives? 1 2 3 Comments: 4. What is your general evaluation of the educational program?
Comments:
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Appendix 4.2
Expert panel covering letter with instructions
Dear experts and seniors:
I am Wen-I Liu, a lecturer at National Taipei College of Nursing and a PhD
candidate at Queensland University of Technology. I am working on my PhD project
“Effectiveness of a collaborative case management education program for Taiwanese
public health nurses”. I have attached an overview of my study and the procedures of
program development. The project was awarded a grant from National Science
Council.
Many thanks for agreeing to review the initial case management education
program. Please rate the items listed and feel free to offer additional comments or
suggestions. I will revise the course content according to your feedback if necessary.
Given time limitations, please return your feedback to the researcher within a two
week period using the envelope provided. Thank you very much for your help!
Sincerely
Researcher: Wen-I Liu Phone Number: (02) 28802526 E-mail: [email protected] 5F, 226, Jil-Her Road Shil-Lin 111, Taipei, Taiwan, R.O.C.
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Appendix 4.3
Expert panel Content Validity Inventory
SECTOR 1 Case management knowledge
Below are a series of items related to general case management concepts and process. Please use the rating scale provided to rate each item from irrelevant to extremely relevant. If you have additional comments, please write them down beside the questions. 1= N=Not relevant 2= S=Somewhat relevant but needs revision 3= Q=Quite Relevant but needs minor alternation 4= V=Very relevant and succinct N S Q V 1. The early roots of case management can be traced to: 1 2 3 4 A The discipline of medicine B The fee-for –service insurance reimbursement C The early practice of social work and public health nursing D The evolution of managed care 2. Which of the following is not true about case management? 1 2 3 4 A It is a new profession. B It is an area of practice within one’s profession. C It is performed by a variety of healthcare providers. D It is performed in a variety of settings. 3 is a system of cost containment programs. 1 2 3 4
A Case management B Managed care C Workers’ compensation D All of the above
4. The essence of the practice of case management ensures that: 1 2 3 4
A The case manager advocates for those patients at risk for hospitalisation, in order that they may go to a lesser level of care.
B The case manager strives to provide quality, cost effective care in the least restrictive setting to all who are at risk, regardless of ability to pay.
C The case manager strives to decrease length of stay as an effective strategy to control health care costs.
D The case manager strives to change physician practice patterns as an effective strategy to control health care cost.
5. The one role that allows the practice of case management to transcend 1 2 3 4 all other disciplines is that of: A Facilitator B Advocate C Collaborator D Mentor
6. All traditional management skills are required for successful 1 2 3 4 case management. Which management skill is emphasised by the
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case manager role in the brokerage model? A Planning B Controlling C Delegating D Linking N S Q V
7. Which management skill is emphasised by the case manager role in the 1 2 3 4 hospital-based case management model?
A Planning B Controlling C Delegating D Linking
8. Which of the following is a systematic process of data collection and 1 2 3 4 analysis involving multiple components and sources?
A Assessment B Evaluation C Implementation D Planning 9. Which case management function is found in each aspect of the 1 2 3 4 case management process? A Evaluation B Monitoring C Interaction D Planning 10. Continuing assessment of the care plan is a part of which process(es): 1 2 3 4 A Initial evaluation B Goals setting C Implementation D Monitoring and evaluation 11. Identification of potential high-risk or high-cost patients is known as: 1 2 3 4 A Case finding and targeting B Planning C Gathering and assessing information D Monitoring 12. The common goals found in case management models are: 1 2 3 4 A Anticipated outcomes and decreased length of stay B Anticipated outcomes and saving cost C Decreased length of stay and saving cost D Anticipated outcomes and appropriateness of care 13. In evaluating a medical plan, what are the main considerations? 1 2 3 4 1 Quality of life 2 Number of treating providers 3 Quantity of money spent on health care 4 Progress of patient A 1,2,3 B 1,3,4 C 1,2,3,4 D 2,3,4 14. The three basic goals of a patient interview are to: 1 2 3 4 1 Provide information 2 Establish rapport 3 Provide a care plan
322
4 Collect information 5 Formulate a care plan A 1,2,3 B 2,3,4 C 1,4,5 D 2,4,5 N S Q V
15. In order to achieve quality care and cost effective outcomes, 1 2 3 4 it is important that:
A Those patients who are most at risk be identified in a timely manner. B The case manager coordinates a plan of care after the initial staffing has taken place. C The patient and family have the appropriate insurance to pay for the plan of care. D The case manager receives three bids for all provider services. 16. A case management plan is: 1 2 3 4 A An outline of the anticipated care required for patients within a specific case type. B An abbreviated version of specific nursing and physician process that must occur to achieve the appropriate length of stay. C A plan of medical care. D An outline of the care mandated for patients within a specific case type.
17. Case managers work in a variety of settings. Which of the following 1 2 3 4 are examples of the provider sector?
1 Managed care organisations or centres 2 Hospital 3 Community-based institutions 4 Long-term care centres A 1,2,3,4 B 2,3,4 C 1,3,4 D 1,2,3 18. The first phase of the case management process is: 1 2 3 4 A Patient identification and section B Examination of the benefits limitations C Assessment of the patient D Development of a treatment plan 19. The role of case manager is that of: 1 2 3 4 A Educator, facilitator, insurance advocate B Assessor, planner, educator, facilitator, patient advocate C Claims, adjuster, planner, educator, facilitator D Assessor, medical planner, facilitator 20. Case manager should complete a provider and service comparison to: 1 2 3 4 A Obtain cost information for the insurer and her own files. B Ensure the quality of the services arranged. C Choose the most cost-effective provider available. D All of the above
323
SECTION 2 Performance confidence in case management skills
Below are a series of statements describing skills of case management. Please use the rating scale provided to rate each item from irrelevant to extremely relevant. 1= N=Not relevant 2= S=Somewhat relevant but needs revision 3= Q=Quite Relevant but needs minor alternation 4= V=Very relevant and succinct N S Q V 1. Assissing client’s level of material resources 1 2 3 4 2. Advocating on behalf of clients 1 2 3 4 3. Making referrals to other services 1 2 3 4 4. Providing information about other service available for clients 1 2 3 4 5. Networking with agencies to coordinate services 1 2 3 4 6. Developing partnerships with clients 1 2 3 4 7. Developing partnerships with clients’ families 1 2 3 4 8 Brokerage needed services to clients 1 2 3 4 9. Collaboration with other service providers 1 2 3 4 10. Interviewing clients 1 2 3 4 11. Interviewing clients’ families 1 2 3 4
324
SECTION 3 Frequency of using case manager role activities
Below are a series of questions relating to activities of nurse case managers. Please use the rating scale provided to rate each item from irrelevant to extremely relevant.
1= N=Not relevant 2= S=Somewhat relevant but needs revision 3= Q=Quite Relevant but needs minor alternation 4= V=Very relevant and succinct
Clinical Practice N S Q V 1 Assess the client as a whole including the context of the environment? 1 2 3 4 2 Rely on the assessment finding of other members of the health care team to
keep abreast of the general health status of groups of clients? 1 2 3 4
3 Communicate with the doctor regarding key assessment finding? 1 2 3 4 4 Use assessment findings to establish mutually set goals with client? 1 2 3 4 5 Use assessment data to plan care through some organised method such as
critical paths, care maps, care plans, or standards of care? 1 2 3 4
6 Collaborate with members of other disciplines to develop critical paths, care
maps, or multi-disciplinary care plans applicable to groups of patients? 1 2 3 4
7 Engage in preadmission planning with client to coordinate such activities as a
diagnostic test, preoperative teaching, travel, or child care? 1 2 3 4
8 Participate in interdisciplinary (cooperation between 2 or more disciplines)
discharge planning? 1 2 3 4
9 Identify community resources (agencies, services) to provide appropriate
care/ services after discharge? 1 2 3 4
10 Communicate with community resources regarding referred clients? 1 2 3 4 11 Coordinate the arrangements for referring clients to community resources? 1 2 3 4 12 Collaborate with informal systems such as family, neighbors, or church
group to provide services needed after discharge but unavailable or inaccessible in community?
1 2 3 4
13 Provide direct nursing care, including delegated medical therapies to clients? 1 2 3 4 14 Coordinate the nursing care activities of staff nurses and other care providers
to assure that multi-disciplinary goals are met? 1 2 3 4
15 Provide guidance to clients regarding their health care choices? 1 2 3 4 16 Use pattern recognition (looking at the whole) to engage clients in seeking
medical/ hospital services before they are severely ill? 1 2 3 4
17 Assist with financial matters such as medicare, medicaid, private insures, or
Social Security? 1 2 3 4
325
N S Q V 18 Participate in quality assurance activities such as monitoring or audits of
client care?
1 2 3 4
19 Documenting deviations from expected client outcomes (variances) 1 2 3 4 20 Taking corrective actions to resolve deviations from expected client
outcomes? 1 2 3 4
21 Follow-up post discharge to assure that the discharge plan is being
implemented? 1 2 3 4
22 Teach the client/ care giver how to manage symptoms of illness? 1 2 3 4 23 Teach the client/ care giver to know when the client needs to seek medical
attention? 1 2 3 4
24 Provide guidance to client/ care giver regarding community resources? 1 2 3 4 25 Make client/ care giver aware of their options? 1 2 3 4 26 Assist clients to exercise options consistent with individually defined health
practices. 1 2 3 4
27 Provide client and care giver with information which allows them to make
informed choices about advanced directives as Living Wills, Durable Power of Attorney or other methods of communicating desires?
1 2 3 4
326
Appendix 5.1
Permissions agreement from Jones and Bartlett Publishers
327
Appendix 5.2
Instrument approval of the Practice Skills Inventory – Case Management Skills
Date: Wed 14 Sep 22:24:56 EST 2005 From: "Thomas O'Hare" <[email protected]> Add To Address Book | This is Spam Subject: Re: a PhD candiate call for help To: <[email protected]>
Wendy--Yes, you may use the PSI in your project. Good luck. Tom
328
Appendix 5.3
Instrument approval of the Case Management Activity Scale
Dear Ms. Liu, Thank you for your interest in the instrument I developed to measure the activities of nurse case managers. I would be delighted for you to use my instrument. You may also be interested in a later publication that speaks to the reliability and validity of the instrument and suggests revisions necessary. The citation for that publication is, "Anderson-Loftin, W. (1999). Developing and testing a case manager impact profile. Nursing Connections, 12(4), 1-26. “I would be interested in hearing how you used the instrument when you complete your dissertation. Sincerely, Wanda Anderson-Loftin, PhD, RN Associate Professor University of South Carolina College of Nursing Columbia, SC 29209
329
Appendix 6.1
Section One: A comparison between two versions of Knowledge Index 1. The early roots of community case management can be traced to: A The discipline of medicine B The fee-for –service insurance reimbursement C The care for the vulnerable populations in the community D The evolution of managed care 2. Which of the following is not true about case management? A It is a new profession. B It is an area of practice within one’s profession. C It is performed by a variety of healthcare providers. D It is performed in a variety of settings. 3 is a system of cost containment programs.
A Case management B Managed care C Workers’ compensation D All of the above
4. The essence of the practice of community case management ensures that: A The case manager strives to provide quality, cost effective care in the least
restrictive setting to all who are at risk, regardless of ability to pay. B The case manager advocates for those patients at risk of rehospitalisation,
in order that they may get needed services in the community. C The case manager strives to decrease length of stay as an effective strategy
to control health care costs. D The case manager strives to change physician practice patterns as an
effective strategy to control health care cost. 5. The one role that allows the practice of case management to transcend all other
disciplines is that of: A Facilitator B Advocate C Collaborator D Mentor
6. All traditional management skills are required for successful case management. Which management skill is emphasised by the case manager role in the brokerage model?
A Planning B Controlling C Delegating D Linking 7. Which management skill is emphasised by the case manager role in the
community-based case management model? A Planning B Controlling C Delegating D Linking 8. Which of the following is a systematic process of data collection and analysis
330
involving multiple components and sources? A Assessment B Evaluation C Implementation D Planning 9. Which case management function is found in each aspect of the case
management process? A Evaluation B Monitoring C Interaction D Planning 10. Continuing assessment of the care plan is a part of which process(es): A Initial evaluation B Goals setting C Implementation D Monitoring and evaluation 11. Identification of potential high-risk or high-cost patients is known as: A Case finding and targeting B Planning C Gathering and assessing information D Monitoring 12. The common goals found in community case management models are: A Anticipated outcomes and decreased length of stay B Ensure to get needed services in the community C Decreased length of stay and saving cost D Anticipated outcomes and appropriateness of care 13. In evaluating a community care plan, what are the main considerations? 1 Quality of life 2 Number of treating providers 3 Quantity of money spent on health care 4 Progress of patient A 1,2,3 B 1,3,4 C 1,2,3,4 D 2,3,4 14. The three basic goals of a patient interview are to: 1 Provide information 2 Establish rapport 3 Provide a care plan 4 Collect information 5 Formulate a care plan A 1,2,3 B 2,3,4 C 1,4,5 D 2,4,5 15. In order to achieve quality care and cost effective outcomes, it is important
that: A Those patients who are most at risk be identified in a timely manner. B The case manager coordinates a plan of care after the initial staffing has
taken place.
331
C The patient and family have the appropriate insurance to pay for the plan of care.
D The case manager receives three bids for all provider services. 16. A community case management plan is: A An outline of the anticipated care required for patients within a specific
case type. B An abbreviated version of specific nursing and physician process that
must occur to achieve the appropriate length of stay. C A plan of medical care. D An outline of the care mandated for patients within a specific case type. 17. Case managers work in a variety of settings. Which of the following are
examples of the community provider sector? 1 Managed care centres 2 Hospital 3 Community-based institutions 4 Long-term care centres A 1,2,3,4 B 2,3,4 C 1,3,4 D 1,2,3 18. The first phase of the case management process is: A Patient identification and selection B Examination of the benefits limitations C Assessment of the patient D Development of a treatment plan 19. The role of case manager is that of: A Educator, facilitator, insurance advocate B Assessor, planner, educator, facilitator, patient advocate C Claims, adjuster, planner, educator, facilitator D Assessor, medical planner, facilitator 20. A long-term goal for the case manager in planning care for a depressed,
suicidal patient would be to: A Assist him to develop more effective coping mechanisms. B Provide him with a safe and structured environment. C Have him sign a “no suicide” contract. D Isolate him from stressful situations that may precipitate a depressive
episode. PS: Modified versions of items in Italic front Items 15 and 16 deleted in the evaluation study
332
Appendix 6.2
Section Two: Adopted and developed items of Case Management Skills
1. Assessing clients’ resource needs 1 2 3 4 5 2. Advocating on behalf of clients 1 2 3 4 5 3. Making referrals to other services 1 2 3 4 5 4. Providing information about other services available
for clients 1 2 3 4 5
5. Networking with agencies to coordinate services 1 2 3 4 5 6. Developing partnerships with clients 1 2 3 4 5 7. Developing partnerships with clients’ families 1 2 3 4 5 8. Linking needed services to clients 1 2 3 4 5 9. Collaborating with other service providers 1 2 3 4 5 10. Interviewing clients 1 2 3 4 5
11. Interviewing clients’ families 1 2 3 4 5
PS: Items developed by the researcher in Italic front
333
Appendix 6.3
Section Three: A comparison between two versions of Case Management Activity
1. Assess the client comprehensively. 1 2 3 4 5 2. Rely on assessment findings to prioritise care needs. 1 2 3 4 5 3. Communicate with clients regarding key assessment
findings. 1 2 3 4 5
4. Use assessment findings to establish mutually set
goals with client. 1 2 3 4 5
5. Use assessment data to develop service plans. 1 2 3 4 5 6. Collaborate with members of other disciplines to
develop multi-disciplinary care plans applicable to groups of patients.
1 2 3 4 5
7. Coordinate acquisition of needed services. 1 2 3 4 5 8. Participate in interdisciplinary service planning. 1 2 3 4 5 9. Identify community resources (agencies, services) to
provide appropriate care/ services. 1 2 3 4 5
10. Communicate with community agencies regarding
referred clients. 1 2 3 4 5
11. Coordinate arrangements when referring clients to community agencies.
1 2 3 4 5
12. Collaborate with informal systems such as family,
neighbours, or religious groups to provide services needed.
1 2 3 4 5
13. Implement service plans, including the acquisition of
medical equipment. 1 2 3 4 5
14. Coordinate the nursing care activities of nurses and
other care providers to assure that multi-disciplinary goals are met.
1 2 3 4 5
15. Provide guidance to clients regarding their health
care choices. 1 2 3 4 5
16. Use pattern recognition (looking at the whole) to
engage clients in seeking medical/ hospital services before they are severely ill.
1 2 3 4 5
334
17. Assist with financial matters such as insurance
premium subsidy, allowance for medium- and low-income families, or subsidy for medical equipment.
1 2 3 4 5
18. Participate in quality assurance activities such as
monitoring or audits of client care. 1 2 3 4 5
19. Documenting deviations from expected client
outcomes. 1 2 3 4 5
20. Take corrective actions to resolve deviations from
expected client outcomes. 1 2 3 4 5
21. Follow-up client responses to services to assure that
the service plan is being implemented. 1 2 3 4 5
22. Teach the client/ care giver how to manage
symptoms of illness. 1 2 3 4 5
23. Teach the client/ care giver to know when the client
needs to seek medical attention. 1 2 3 4 5
24. Provide guidance to client regarding community
resources. 1 2 3 4 5
25. Make client aware of their options. 1 2 3 4 5 26. Assist clients to exercise options consistent with
individually defined health practices. 1 2 3 4 5
27. Provide client/ care giver with information on related
care goals of clients. 1 2 3 4 5
PS: Modified versions of items in Italic front
335
Appendix 6.4
Section Four: Evaluation items for the post-tests
of the experimental group
Direction: Below are a series of questions relating to general evaluation of the program. Please circle the most appropriate response and provide the data requested. 1. Are you satisfied with the program?
1 2 3 4 5 Not at all A little Moderately Satisfied Very satisfied
2. Is the program helpful?
1 2 3 4 5 Not at all A little Moderately helpful Very helpful
3. Is the program necessary?
1 2 3 4 5 Not at all A little Moderately Necessary Very necessary
THANK YOU FOR YOUR VALUABLE ASSISTANCE WITH THIS RESEARCH
336
Appendix 7.1
Ethical approval from Queensland University of Technology
Date: Wed 5 Oct 12:41:09 EST 2005 From: Wendy Heffernan <[email protected]> Add To Address Book | This is Spam Subject: Level 2 (Expedited) Ethical Clearance - 4236H To: [email protected] Cc: [email protected] Dear Wen-I I write further to the application for Level 2 (Expedited) ethical clearance requested for your project, "Develop, implement and evaluate a collaborative case management education program for Taiwanese public health nurses" (QUT Ref No 4236H). This application was recently considered by the University Human Research Ethics Committee (UHREC) Expedited Ethical Review Panel. On behalf of the Panel I wish to advise that your project has been granted ethical approval. Consequently, you are authorised to immediately commence your project on this basis. The decision is subject to ratification at the 29 November 2005 meeting of UHREC. I will only contact you again in relation to this matter if the Committee raises any additional questions or concerns in regard to the clearance. The University requires its researchers to comply with:
• the University’s research ethics arrangements and the QUT Code of Conduct for Research; • the standard conditions of ethical clearance; • any additional conditions prescribed by the UHREC; • any relevant State / Territory or Commonwealth legislation; • the policies and guidelines issued by the NHMRC and AVCC (including the National
Statement on Ethical Conduct in Research Involving Humans).
Please do not hesitate to contact me further if you have any queries regarding this matter. Regards Wendy Wendy Heffernan | Research Ethics Officer Office of Research | Queensland University of Technology | GPO Box 2434, Brisbane QLD 4001 | phone: 07 3864 2340 | fax: 07 3864 1304 | email: [email protected] | CRICOS No. 00213J
337
Appendix 7.2
Ethical approval from National Taipei College of Nursing
338
Appendix 8
Approval of the twelve health centres in Taipei City
Health Centre (in Chinese) Health Centre (in English)
1.士林區健康服務中心 8.1.Shih- Lin District Health Centre
2.信義區健康服務中心 8.2.Hsin-I District Health Centre
3.萬華區健康服務中心 8.3.Wan-Hau District Health Centre
4.中正區健康服務中心 8.4.Zhong Zheng District Health Centre
5.大同區健康服務中心 8.5.Da-Tong District Health Centre
6.大安區健康服務中心 8.6.Da-An District Health Centre
7.北投區健康服務中心 8.7.Pei-Tou District Health Centre
8.中山區健康服務中心 8.8.Zhung-Shan District Health Centre
9.內湖區健康服務中心 8.9.Nei-Hu District Health Centre
10.文山區健康服務中心 8.10.Wen-Shan District Health Centre
11.南港區健康服務中心 8.11.Nan-Kang District Health Centre
12.松山區健康服務中心 8.12.Sung-Shan District Health Centre
339
Appendix 8.1
Approval of the Health Centre 1
340
Appendix 8.2
Approval of the Health Centre 2
341
Appendix 8.3
Approval of the Health Centre 3
342
Appendix 8.4
Approval of the Health Centre 4
343
Appendix 8.5
Approval of the Health Centre 5
344
Appendix 8.6
Approval of the Health Centre 6
345
Appendix 8.7
Approval of the Health Centre 7
346
Appendix 8.8
Approval of the Health Centre 8
347
Appendix 8.9
Approval of the Health Centre 9
348
Appendix 8.10
Approval of the Health Centre 10
349
Appendix 8.11
Approval of the Health Centre 11
350
Appendix 8.12
Approval of the Health Centre 12
351
Appendix 9.1
Survey on case management
Queensland University of Technology National Taipei College of Nursing
352
Instructions
7. The aim of this questionnaire is to explore your current practice related
to case management.
8. It asks for your general understanding and experiences regarding case
management.
9. All answers will be treated confidentially and your individual answers will
not be shared with anyone.
10. Please answer every question by marking the answer as indicated.
11. There are no right or wrong answers. If you are unsure how to answer a
question please give the best answer you can.
12. After you have completed the questionnaire please place it in the
envelope supplied and return it to the researcher.
353
Direction: Below are a series of items related to general case management concepts and process. Please circle the ONE response that corresponds to your best answer. 1. The early roots of community case management can be traced to: A The discipline of medicine B The fee-for –service insurance reimbursement C The care for the vulnerable populations in the community D The evolution of managed care 2. Which of the following is not true about case management? A It is a new profession. B It is an area of practice within one’s profession. C It is performed by a variety of healthcare providers. D It is performed in a variety of settings. 3 is a system of cost containment programs.
A Case management B Managed care C Workers’ compensation D All of the above
4. The essence of the practice of community case management ensures that: A The case manager strives to provide quality, cost effective care in the least
restrictive setting to all who are at risk, regardless of ability to pay. B The case manager advocates for those patients at risk of rehospitalisation, in
order that they may get needed services in the community. C The case manager strives to decrease length of stay as an effective strategy to
control health care costs. D The case manager strives to change physician practice patterns as an effective
strategy to control health care cost. 5. The one role that allows the practice of case management to transcend all other
disciplines is that of: A Facilitator B Advocate C Collaborator D Mentor
6. All traditional management skills are required for successful case management. Which management skill is emphasised by the case manager role in the brokerage model?
A Planning B Controlling C Delegating D Linking
SECTION 1 Case management knowledge
354
7. Which management skill is emphasised by the case manager role in the community-based case management model?
A Planning B Controlling C Delegating D Linking 8. Which of the following is a systematic process of data collection and analysis
involving multiple components and sources? A Assessment B Evaluation C Implementation D Planning 9. Which case management function is found in each aspect of the case
management process? A Evaluation B Monitoring C Interaction D Planning 10. Continuing assessment of the care plan is a part of which process(es): A Initial evaluation B Goals setting C Implementation D Monitoring and evaluation 11. Identification of potential high-risk or high-cost patients is known as: A Case finding and targeting B Planning C Gathering and assessing information D Monitoring 12. The common goals found in community case management models are: A Anticipated outcomes and decreased length of stay B Ensure to get needed services in the community C Decreased length of stay and saving cost D Anticipated outcomes and appropriateness of care 13. In evaluating a community medical plan, what are the main considerations? 1 Quality of life 2 Number of treating providers 3 Quantity of money spent on health care 4 Progress of patient A 1,2,3 B 1,3,4 C 1,2,3,4 D 2,3,4 14. The three basic goals of a patient interview are to: 1 Provide information 2 Establish rapport 3 Provide a care plan 4 Collect information 5 Formulate a care plan A 1,2,3 B 2,3,4
355
C 1,4,5 D 2,4,5 15. In order to achieve quality care and cost effective outcomes, it is important that: A Those patients who are most at risk be identified in a timely manner. B The case manager coordinates a plan of care after the initial staffing has
taken place. C The patient and family have the appropriate insurance to pay for the plan of
care. D The case manager receives three bids for all provider services. 16. A community case management plan is: A An outline of the anticipated care required for patients within a specific
case type. B An abbreviated version of specific nursing and physician process that must
occur to achieve the appropriate length of stay. C A plan of medical care. D An outline of the care mandated for patients within a specific case type. 17. Case managers work in a variety of settings. Which of the following are
examples of the community provider sector? 1 Managed care centres 2 Hospital 3 Community-based institutions 4 Long-term care centres A 1,2,3,4 B 2,3,4 C 1,3,4 D 1,2,3 18. The first phase of the case management process is: A Patient identification and selection B Examination of the benefits limitations C Assessment of the patient D Development of a treatment plan 19. The role of case manager is that of: A Educator, facilitator, insurance advocate B Assessor, planner, educator, facilitator, patient advocate C Claims, adjuster, planner, educator, facilitator D Assessor, medical planner, facilitator 20. A long-term goal for the case manager in planning care for a depressed, suicidal
patient would be to: A Assist him to develop more effective coping mechanisms. B Provide him with a safe and structured environment. C Have him sign a “no suicide” contract. D Isolate him from stressful situations that may precipitate a depressive
episode.
356
Direction: Below are a series of statements describing case management skills. Please circle ONE number on the five point scale below which best indicates your confidence in your current case management practice.
Very low confidence = 1; Low confidence = 2; Average confidence =3; High confidence = 4; Very high confidence= 5
Please rate your current level of confidence in performing the following: Ve
ry lo
w
Low
Ave
rage
Hig
h
Very
hig
h
1. Assessing clients’ resource needs 1 2 3 4 5 2. Advocating on behalf of clients 1 2 3 4 5 3. Making referrals to other services 1 2 3 4 5 4. Providing information about other services available
for clients 1 2 3 4 5
5. Networking with agencies to coordinate services 1 2 3 4 5 6. Developing partnerships with clients 1 2 3 4 5 7. Developing partnerships with clients’ families 1 2 3 4 5 8. Linking needed services to clients 1 2 3 4 5 9. Collaborating with other service providers 1 2 3 4 5 10. Interviewing clients 1 2 3 4 5 11. Interviewing clients’ families 1 2 3 4 5
SECTION 2 Performance of case management skills
357
Direction: Below are a series of statements describing case management skills. Please circle ONE number on the five point scale below which best indicates how frequently you currently use the identified skill. Never = 1; Rarely = 2; Sometimes = 3; Often = 4; Very often = 5 Please rate how frequently you actually use the following case management skills in your current practice: N
ever
Rar
ely
Som
etim
es
Ofte
n
Very
Ofte
n
1. Assess clients’ resource needs 1 2 3 4 5 2. Advocate on behalf of clients 1 2 3 4 5 3. Make referrals to other services 1 2 3 4 5 4. Provide information about other services available
for clients 1 2 3 4 5
5. Network with agencies to coordinate services 1 2 3 4 5 6. Developing partnerships with clients 1 2 3 4 5 7. Developing partnerships with clients’ families 1 2 3 4 5 8. Link needed services to clients 1 2 3 4 5 9. Collaborate with other service providers 1 2 3 4 5 10. Interview clients 1 2 3 4 5 11. Interview clients’ families 1 2 3 4 5
358
Direction: Below are a series of statements relating to the activities of nurse case managers. Please circle ONE number which best describes your level you of preparation to perform the selected activity.
Very low preparation=1; low preparation =2; Average preparation=3; High preparation=4; Very high preparation=5 Please rate your preparedness level for performing the following activities: Ve
ry lo
w
Low
Ave
rage
Hig
h
Ver
y hi
gh
1. Assess the client comprehensively. 1 2 3 4 5 2. Rely on assessment findings to prioritise care needs. 1 2 3 4 5 3. Communicate with clients regarding key assessment findings. 1 2 3 4 5 4. Use assessment findings to establish mutually set goals with client. 1 2 3 4 5 5. Use assessment data to develop service plans. 1 2 3 4 5 6. Collaborate with members of other disciplines to develop multi-
disciplinary care plans applicable to groups of patients. 1 2 3 4 5
7. Coordinate acquisition of needed services. 1 2 3 4 5 8. Participate in interdisciplinary service planning. 1 2 3 4 5 9. Identify community resources (agencies, services) to provide
appropriate care/ services. 1 2 3 4 5
10. Communicate with community agencies regarding referred clients. 1 2 3 4 5
11. Coordinate arrangements when referring clients to community agencies.
1 2 3 4 5
12. Collaborate with informal systems such as family, neighbours, or
religious groups to provide services needed. 1 2 3 4 5
13. Implement service plans, including the acquisition of medical
equipment. 1 2 3 4 5
14. Coordinate the nursing care activities of nurses and other care
providers to assure that multi-disciplinary goals are met. 1 2 3 4 5
15. Provide guidance to clients regarding their health care choices. 1 2 3 4 5 16. Use pattern recognition (looking at the whole) to engage clients in
seeking medical/ hospital services before they are severely ill. 1 2 3 4 5
SECTION 3 Preparedness and use of case manager role activities
359
Please rate your preparedness level for performing the following activities: Ve
ry lo
w
Low
Ave
rage
Hig
h
Ver
y hi
gh
17. Assist with financial matters such as insurance premium subsidy, allowance for medium- and low-income families, or subsidy for medical equipment.
1 2 3 4 5
18. Participate in quality assurance activities such as monitoring or
audits of client care. 1 2 3 4 5
19. Documenting deviations from expected client outcomes. 1 2 3 4 5 20. Take corrective actions to resolve deviations from expected client
outcomes. 1 2 3 4 5
21. Follow-up client responses to services to assure that the service plan
is being implemented. 1 2 3 4 5
22. Teach the client/ care giver how to manage symptoms of illness. 1 2 3 4 5 23. Teach the client/ care giver to know when the client needs to seek
medical attention. 1 2 3 4 5
24. Provide guidance to client regarding community resources. 1 2 3 4 5 25. Make client aware of their options. 1 2 3 4 5 26. Assist clients to exercise options consistent with individually
defined health practices. 1 2 3 4 5
27. Provide client/ care giver with information on related care goals of
clients. 1 2 3 4 5
360
Direction: Below are a series of statements relating to the activities of nurse case managers. Please circle ONE number which best describes how frequently you currently perform the selected activity.
Never = 1; Rarely = 2; Sometimes = 3; Often = 4; Very often = 5
Please rate how frequently you actually use the following activities in your current practice: N
ever
Rar
ely
Som
etim
e
Ofte
n
Very
Ofte
n
1. Assess the client comprehensively. 1 2 3 4 5 2. Rely on assessment findings to prioritise care needs. 1 2 3 4 5 3. Communicate with clients regarding key assessment findings. 1 2 3 4 5 4. Use assessment findings to establish mutually set goals with client. 1 2 3 4 5 5. Use assessment data to develop service plans. 1 2 3 4 5 6. Collaborate with members of other disciplines to develop multi-
disciplinary care plans applicable to groups of patients. 1 2 3 4 5
7. Coordinate acquisition of needed services. 1 2 3 4 5 8. Participate in interdisciplinary service planning. 1 2 3 4 5 9. Identify community resources (agencies, services) to provide
appropriate care/ services. 1 2 3 4 5
10. Communicate with community agencies regarding referred clients. 1 2 3 4 5 11. Coordinate arrangements when referring clients to community
agencies. 1 2 3 4 5
12. Collaborate with informal systems such as family, neighbours, or
religious groups to provide services needed. 1 2 3 4 5
13. Implement service plans, including the acquisition of medical
equipment. 1 2 3 4 5
14. Coordinate the nursing care activities of nurses and other care
providers to assure that multi-disciplinary goals are met. 1 2 3 4 5
15. Provide guidance to clients regarding their health care choices. 1 2 3 4 5 16. Use pattern recognition (looking at the whole) to engage clients in
seeking medical/ hospital services before they are severely ill. 1 2 3 4 5
17. Assist with financial matters such as insurance premium subsidy,
allowance for medium- and low-income families, or subsidy for medical equipment.
1 2 3 4 5
18. Participate in quality assurance activities such as monitoring or audits
of client care. 1 2 3 4 5
361
Please rate how frequently you: N
ever
Rar
ely
Som
etim
e
Ofte
n
Very
Ofte
n
19. Documenting deviations from expected client outcomes. 1 2 3 4 5 20. Take corrective actions to resolve deviations from expected client
outcomes. 1 2 3 4 5
21. Follow-up client responses to services to assure that the service plan is
being implemented. 1 2 3 4 5
22. Teach the client/ care giver how to manage symptoms of illness. 1 2 3 4 5 23. Teach the client/ care giver to know when the client needs to seek
medical attention. 1 2 3 4 5
24. Provide guidance to client regarding community resources. 1 2 3 4 5 25. Make client aware of their options. 1 2 3 4 5 26. Assist clients to exercise options consistent with individually defined
health practices. 1 2 3 4 5
27. Provide client/ care giver with information on related care goals of
clients. 1 2 3 4 5
362
Direction: Below are a series of questions relating to general information about you. Please circle the most appropriate response and provide the data requested. 1. Gender 1 Male 2 Female 2. Highest qualification in Nursing 1 Diploma in Nursing 2 Associate Degree in Nursing 3 Baccalaureate in Nursing 4 Master in Nursing 5 Other (Please specify) 3. Age at last birthday (Please insert the number of years) years 4. How long have you practiced nursing? (Please insert the number of years) years 5. How long have you been a public health nurse? (Please insert the number of years) years 6. Have you attended any case management seminars, conference, or workshops? 1 No 2 Yes, Please write down the total contact hours: hours For pos-tests of the experimental group 1. Are you satisfied with the program?
1 2 3 4 5 Not at all A little Moderately Satisfied Extremely
2. Is the program helpful?
1 2 3 4 5 Not at all A little Moderately Helpful Extremely
4. Is the program necessary?
1 2 3 4 5 Not at all A little Moderately Necessary Extremely
THANK YOU FOR YOUR VALUABLE ASSISTANCE WITH THIS RESEARCH
SECTION 4 Demographic information
363
Appendix 9.2
Questionnaire in Chinese
澳洲昆士蘭科技大學 國立臺北護理學院
個案管理問卷調查
指示
1. 本問卷的目的是探討您目前個案管理相關的實務工作。
2. 問卷會問及您對個案管理的一般了解與經驗。
3. 所有的答案都將被保密,而且您個人的答案絕不會被公開。封面右下角空白處為您自設之代碼,請以您在原生家庭之排行為第一個數字,其它後四個數字為您的身份證末四碼,共有五個數字。
4. 回答每一個問題時,請遵照指示選擇答案。
5. 這些問題沒有正確或是錯誤的答案。假如您不確定該如何回答一項問題時,請選擇一個最合適的答案。
6. 完成問卷後,請將它放入信封袋內交還給工作人員。
364
指示:以下是一系列關於一般個案管理的概念與過程的描述。請勾選一項您覺得最適合的答案。 1. 台灣社區個案管理的起源背景為: A 強調社區醫療之專業團隊照顧 B 促使社區醫療保險之給付 C 確保弱勢族群得到社區照顧 D 管理式照顧之興起 2. 下列關於個案管理的描述,何者錯誤? A 它是一項新專業 B 它是專業中的一項實務工作方法 C 它可由不同的健康照顧人員提供 D 它可執行在許多不同的環境中 3. 以控制醫療成本為核心的照顧系統稱為: A 個案管理 B 管理式照顧 C 照顧管理 D 監控照顧 4. 實施社區個案管理可以確保: A 不讓個案的病況變差 B 可能入院的高危險個案得到適當之社區照顧服務 C 有效控制醫療成本費用 D 改變醫師為病人做診治的方式 5. 下列何種角色能讓個案管理的運作跨越其他的專業? A 協調者 B 代言者 C 合作者 D 指導者 6. 要能有成功的個案管理必須具備所有傳統管理的技巧。在轉介模式中,個案管理人這個
角色最需要何種管理技巧?
第一部分 個案管理的知識
365
A 計劃 B 控制 C 授權 D 連結 7. 以社區為基礎的管理模式中,個案管理人這個角色最需要何種管理技巧? A 計劃 B 控制 C 授權 D 連結 8. 引用多種來源的系統化資料搜集與分析的方法稱為: A 評估 B 評價 C 執行 D 計劃 9. 在整個個案管理過程中都能發現到個案管理的那一種功能? A 評價 B 監控 C 互動 D 計劃 10. 對照顧計劃的持續評估是何種過程的一部分? A 初步的評估 B 設定目標 C 執行 D 監控和評值 11. 確認那些個案為高危險或可能耗費高醫療成本的過程稱為: A 發現並確認個案 B 計劃 C 搜集及評估資料 D 監測 12. 社區個案管理常見的主要目標為: A 達成預期醫療結果 B 確保個案得到所需之資源 C 減少整體社區醫療花費 D 督促社區醫療人員執行服務
366
13. 在評價一項社區照顧計劃時,何者是主要的考量? 1 生活的品質 2 社區服務提供者的數目 3 應用在醫療服務的費用 4 個案的進展 A 1, 2, 3 B 1, 3, 4 C 1, 4 D 2, 3, 4 14. 與個案進行會談時的三項基本目標是: 1 提供資訊 2 建立良好關係 3 提供照顧計劃 4 搜集資料 5 建立照顧計劃 A 1, 2, 3 B 2, 3, 4 C 1, 4, 5 D 2, 4, 5 15. 為了要能有高品質的健康服務以及符合經濟效益的結果,重要的是: A 必須及時確認出高危險的個案 B 個案管理人介後協調照顧計劃 C 個案及其家屬必須要有適當的保險來負擔醫療計劃的費用 D 個案管理人須比較所有服務項目之費用 16. 社區個案管理的計劃是: A 針對患有某種特定病症的個案,預先設想所需的醫療照護而擬定的大綱 B 為了減少社區個案再入院之機率所列出的特定照護和診治過程的簡述 C 針對社區民眾之整體醫療方面的社區計劃 D 針對患有某種特定病症的個案所擬出個案需進行的醫療照護 17. 個案管理人可在各種不同環境下工作。下列何者為社區健康照顧提供者的典型? 1 健康服務中心 2 醫院 3 以社區為中心的機構 4 長期照護中心 A 3, 4 B 2, 3, 4 C 1, 3, 4 D 1, 2, 3 18. 個案管理過程的第一個階段是:
367
A 篩選及確認個案 B 審視照護結果之限制 C 評估個案 D 發展治療計劃 19. 個案管理人扮演的角色涵蓋: A 教育者,協調者,病患權益的維護者 B 評估者,計劃者,服務提供者,協調者,病患權益的維護者 C 計劃者,教育者,協調者,服務提供者 D 評估者,計劃者,協調者,服務提供者 20. 個案管理人爲患有重鬱症並有自殺傾向的個案所訂的長期目標應是: A 協助個案發展出更有效的處理方式 B 提供個案一個安全,結構性的環境 C 讓個案簽下一份”不會自殺”的契約 D 隔離個案免於可能促使他自殺的壓力情境
368
指示:以下是一系列關於個案管理技巧的描述。請在決定那個選項最能表達自己對個案管理技
巧的信心後,再從五分的評價表中圈選一個數目。 信心非常低 = 1; 信心低落 = 2; 信心在平均左右 = 3
;
高度信心 = 4; 信心非常高 = 5 在進行下列的工作時,你對自己有多大的信心?請評分: 非常低 低 平均 高 非常高1. 評估個案在資源方面的需求 1 2 3 4 5
2. 代表個案維護他的權利 1 2 3 4 5
3. 轉介其他的服務給個案 1 2 3 4 5
4. 提供有關可利用之服務資訊給個案 1 2 3 4 5
5. 與服務機構建立起聯絡網來協調各項服務 1 2 3 4 5
6. 與個案建立良好關係 1 2 3 4 5
7. 與個案的家人建立良好的關係 1 2 3 4 5
8. 連結個案所需要的服務 1 2 3 4 5
9. 與其他的服務提供者合作 1 2 3 4 5
10. 運用溝通技巧訪談個案 1 2 3 4 5
11. 運用溝通技巧訪談個案的家人 1 2 3 4 5
第二部分 個案管理的技巧
369
指示:以下是一系列關於個案管理技巧的描述。請在決定那個選項最能反映出
自己應用到個案管理技巧有多頻繁後,從五分的評價表中圈選一個選項。 從不 = 1; 很少 = 2; 有時 = 3; 時常 =4; 很頻繁 = 5 你有多常應用到個案管理技巧?請評分: 從不 很少 有時 時常 很頻繁1. 評估個案在資源方面的需求 1 2 3 4 5
2. 代表個案維護他的權利 1 2 3 4 5
3. 轉介其他的服務給個案 1 2 3 4 5
4. 提供有關可利用之服務資訊給個案 1 2 3 4 5
5. 與服務機構建立起聯絡網來協調各項服務 1 2 3 4 5
6. 與個案建立良好關係 1 2 3 4 5
7. 與個案的家人建立良好的關係 1 2 3 4 5
8. 連結個案所需要的服務 1 2 3 4 5
9. 與其他的服務提供者合作 1 2 3 4 5
10. 運用溝通技巧訪談個案 1 2 3 4 5
11. 運用溝通技巧訪談個案的家人 1 2 3 4 5
370
指示:以下是一系列關於護理個案管理相關活動的描述。請在決定那個選項最能反映出自己在
某個特定活動的準備度後,圈選一個最合適數字。
極低的準備度 = 1; 低的準備度 = 2; 平均的準備度 = 3;
高的準備度 = 4; 極高的準備度 = 5 請給自己在進行下列活動的準備程度做評分 極低 低 平均 高 極高 1. 對個案進行整體評估 1 2 3 4 5
2. 依據評估結果,列出個案照顧需求之優先順序 1 2 3 4 5
3. 與個案溝通重要的評估結果 1 2 3 4 5
4. 運用評估結果,與個案建立一個雙方都能接受的照顧目標 1 2 3 4 5
5. 利用評估所得的資料發展服務計劃 1 2 3 4 5
6. 與其他相關人員合力發展適用於特定群組的多元化照顧計劃 1 2 3 4 5
7. 協調獲取個案所需要的服務 1 2 3 4 5
8. 參與跨領域的服務策劃 1 2 3 4 5
9. 識別社區資源(如服務機構或服務業者)來提供合適的照護
服務
1 2 3 4 5
10. 與社區轉介機構溝通個案相關訊息 1 2 3 4 5
11. 協調安排轉介個案到社區相關機構 1 2 3 4 5
12. 與家屬,鄰居,或團體等的非正式系統合力提供所需的服務 1 2 3 4 5
接下頁
第三部分 個案管理的角色活動
371
請給自己在進行下列活動的準備程度做評分 極低 低 平均 高 極高13. 執行服務計劃,包括醫療設備的取得 1 2 3 4 5
14. 協調其他服務提供者之照顧活動,以確保達成社區照顧的目
標
1 2 3 4 5
15. 提供個案選擇照顧服務項目的導引 1 2 3 4 5
16. 以整體考量來協助個案尋求醫療服務 1 2 3 4 5
17. 在財務方面協助病人,例如提供保險費補助,中低收入戶津
貼,或是醫療設備方面補助之資訊,必要時協助爭取
1 2 3 4 5
18. 參與確保醫療品質的活動,例如對個案的照護方面的監控與
審核
1 2 3 4 5
19. 個案沒有達到預期的目標時,詳做記錄 1 2 3 4 5
20. 個案沒有達到預期的目標時,採取行動設法解決 1 2 3 4 5
21. 在個案接受服務後,調查個案對服務的回應,以確保服務之
品質
1 2 3 4 5
22. 教導個案如何處理疾病的症狀 1 2 3 4 5
23. 教導個案查覺本身何時需要尋求醫療診治 1 2 3 4 5
24. 提供個案關於社區相關服務資源的導引 1 2 3 4 5
25. 讓個案了解自己可以有不同選擇 1 2 3 4 5
26. 協助個案選擇所需之醫療服務項目 1 2 3 4 5
27. 提供個案與照顧目標相關的資訊 1 2 3 4 5
372
指示:以下是一系列關於護理個案管理者活動的描述。請在決定那個選項最能反映出自己在執
行某個特定活動有多頻繁後,圈選一個最合適的數字。
從不 = 1; 很少 = 2; 有時 = 3; 時常 = 4; 很頻繁 = 5 你常常執行這些活動嗎? 請評分: 從不 很少 有時 時常 很頻
繁 1. 對個案進行整體評估 1 2 3 4 5
2. 依據評估結果,列出個案照顧需求之優先順序 1 2 3 4 5
3. 與個案溝通重要的評估結果 1 2 3 4 5
4. 運用評估結果,與個案建立一個雙方都能接受的照顧目標 1 2 3 4 5
5. 利用評估所得的資料發展服務計劃 1 2 3 4 5
6. 與其他相關人員合力發展適用於特定群組的多元化照顧計
劃
1 2 3 4 5
7. 協調獲取個案所需要的服務 1 2 3 4 5
8. 參與跨領域的服務策劃 1 2 3 4 5
9. 識別社區資源(如服務機構或服務業者)來提供合適的照
護服務
1 2 3 4 5
10. 與社區轉介機構溝通個案相關訊息 1 2 3 4 5
11. 協調安排轉介個案到社區相關機構 1 2 3 4 5
12. 與家屬,鄰居,或團體等的非正式系統合力提供所需的服
務
1 2 3 4 5
接下頁
373
你常常執行這些活動嗎? 請評分: 從不 很少 有時 時常 很頻
繁 13. 執行服務計劃,包括醫療設備的取得 1 2 3 4 5
14. 協調其他服務提供者之照顧活動,以確保達成社區照顧的
目標
1 2 3 4 5
15. 提供個案選擇照顧服務項目的導引 1 2 3 4 5
16. 以整體考量來協助個案尋求醫療服務 1 2 3 4 5
17. 在財務方面協助病人,例如提供保險費補助,中低收入戶
津貼,或是醫療設備方面補助之資訊,必要時協助爭取
1 2 3 4 5
18. 參與確保醫療品質的活動,例如對個案的照護方面的監控
與審核
1 2 3 4 5
19. 個案沒有達到預期的目標時,詳做記錄 1 2 3 4 5
20. 個案沒有達到預期的目標時,採取行動設法解決 1 2 3 4 5
21. 在個案接受服務後,調查個案對服務的回應,以確保服務
之品質
1 2 3 4 5
22. 教導個案如何處理疾病的症狀 1 2 3 4 5
23. 教導個案查覺本身何時需要尋求醫療診治 1 2 3 4 5
24. 提供個案關於社區相關服務資源的導引 1 2 3 4 5
25. 讓個案了解自己可以有不同選擇 1 2 3 4 5
26. 協助個案選擇所需之醫療服務項目 1 2 3 4 5
27. 提供個案與照顧目標相關的資訊 1 2 3 4 5
374
指示:以下是一系列對於您的一般資料的問題。請圈選最貼切的答案,並按指示提供相關資料。 1. 性別 1 男性 2 女性 2. 在護理方面取得的最高學歷 1 護理高職畢業 2 護理專科畢業 3 護理系學士學位 4 護理系碩士學位 5 其他(請詳細寫出)______________________________________ 3. 過完上一個生日時的年齡(請寫下足歲數) _____________________歲 4. 你從事護理業已有多久的時間了?(請寫年數) _____________________年 5. 你從事公共衛生護士已有多久的時間了?(請寫年數,未滿一年請寫月數) _____________________年 6. 你曾參加過任何關於個案管理的課程,會議,或是研習會嗎? 1 否 2 是。請寫下接觸到這些活動的總時數:________________小時
謝謝您為本研究提供珍貴之協助
第四部分
個人的基本資料
373
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