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.

10

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).

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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

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(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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

219

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.

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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: wenyi@ntcn.edu.tw

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: h.edwards@qut.edu.au). 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 ethicscontact@qut.edu.au. 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: wenyi@ntcn.edu.tw 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 ethicscontact@qut.edu.au 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: wenyi@ntcn.edu.tw

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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

310

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: wenyi@ntcn.edu.tw 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" <oharet@bc.edu> Add To Address Book | This is Spam Subject: Re: a PhD candiate call for help To: <wi.liu@student.qut.edu.au>

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 <w.heffernan@qut.edu.au> Add To Address Book | This is Spam Subject: Level 2 (Expedited) Ethical Clearance - 4236H To: wi.liu@student.qut.edu.au Cc: h.edwards@qut.edu.au 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: w.heffernan@qut.edu.au | 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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