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Purpose/Objectives: The role of a nurse case manager (NCM) incorporates practice that is built upon knowledge gained in other roles as well as components unique to case management. The concept of reflective practice was used in creating a framework to recognize the developmental stages that occur within community based case management practice. The formation of this framework and its uses are described in this article.
Primary Practice Setting: The practice setting is a community based case management department in a large midwestern metropolitan health care system with Magnet recognition. Advanced practice nurses provide care for clients with chronic health conditions.
Findings/Conclusions: Twenty-four narratives were used to identify behaviors of community based case managers and to distinguish stages of practice. The behaviors of advanced practice found within the narratives were labeled and analyzed for similarities. Related behaviors were grouped and descriptor statements were written. These statements grouped into 3 domains of practice: relationship/partnership, coordination/collaboration, and clinical knowledge/decision making. The statements in each domain showed practice variations from competent to expert, and 3 stages were determined. Reliability and validity of the framework involved analysis of additional narratives. The reflective practice process, used for monthly case review presentations, provides opportunity for professional development and group learning focused on improving case manager practice. The framework is also being used in orientation as new case managers acclimate to the role.
Implications for Case Management Practice: Reflective writing has unveiled the richness and depth of nurse case manager practice. The depth of knowledge and skills involved in community-based case management is captured within this reflective practice framework. This framework provides a format for describing community based case manager practice development over the course of time and has been used as a tool for orientation and peer review.
The role of the case manager has become crucial to the success of the health care team. Acquisition of competency and advancement to expertise in the role of the case manager is a developmental process that involves experience, mentoring, continuing education, self-reflection, and peer review. Case management, as defined by the Case Management Society of America (CMSA) Standards of Practice for Case Management (CMSA, 2010), is "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to facilitate an individual's and family's comprehensive health needs through communication and available resources to promote quality cost-effective outcomes" (p. 6). Case Management Society of America further defines case management as an "advanced practice" (p. 4) and recognizes that the role requires "specialized skills and knowledge" to effect positive outcomes. This article describes the formation and application of an advanced practice professional development framework. The concept of reflective practice was used to create this framework that recognizes the developmental stages occurring within community-based case management practice.
The Community Based Case Management (CBCM) department's advanced practice nurses (APNs) provide comprehensive clinical coordination of care and case management within a Magnet-recognized, integrated health delivery system in a midwestern metropolitan area. Clients referred to the CBCM program have complex, chronic health conditions; suboptimal health management; multiple specialty providers; and a history of high or inappropriate service utilization. Referral sources include inpatient and ambulatory caregivers, home health care providers, and physicians along with intradepartmental case finding. Nurse case managers (NCMs) provide care primarily in clients' homes, although visits may also occur in physicians' offices, the hospital, or other settings in the community. Nurse case managers partner with clients, families, health care team members, and community providers to establish goals that support efficient and effective use of health care resources. Clients are supported to access knowledge, skills, and resources to meet their needs and improve their health. There is an emphasis on helping clients to understand their health conditions and to acknowledge the relationship their choices have on the health-related consequences that ensue. The role of the NCM also involves coaching clients on how to communicate with their providers, and assisting them to be an integral part of health care decision making. In addition, NCMs are accountable for meeting CBCM program outcomes involving clinical quality, satisfaction, and financial measurement indicators.
The health care system with which CBCM is affiliated has a long history of shared governance and support of nursing practice accountability. In the early 1990s, a practice-focused peer review and advancement model for inpatient staff nurses was adopted. Staff wrote first-person narratives reflecting upon their clinical practice. This writing and related peer discussion allowed the depth and breadth of knowledge, as well as growth opportunities, to be identified. The Clinical Practice Development Model (CPDM) was based on the Dreyfus Model of Skill Acquisition, and the Novice to Expert Framework developed by Patricia Benner (Haag-Heitman, 1999).
Nurse case manager staff recognized the challenge and discomfort in transitioning to the NCM role after having mastered another area of advanced practice. Moran (2010) described his unexpectedly difficult adjustment from expert emergency department nurse to a novice when taking on the new role of complex medical case manager. When new NCM staff joined the CBCM department, the idea of developing an advanced practice framework to normalize this transition process was proposed. Nurse case managers also saw the opportunity to explore the unique behaviors of the role and to create a framework grounded in professional practice. Group consensus reached at a department strategic planning session resulted in the formation of a project team that took on this endeavor. Because of familiarity and experience with the CPDM and Benner models, the team chose to write narrative stories to describe NCM practice and the developmental journey. Anticipated applications of the framework included staff orientation, mentoring, ongoing professional learning, and advancing practice development.
The project team began by looking for existing professional development models or frameworks for advanced practice nursing to support and inform the work. As the practice development model evolved, the literature was regularly reviewed for exploration of new thinking and validation of the work in progress.
Articles were found describing APN competency assessment (Davies and Hughes, 2002) and providing tools to measure outcomes for APNs in primary provider roles (i.e., nurse practitioner; Kish, 2001). Briggs, Heath, and Kelley (2005) provide a tool for APN peer review in a critical care setting, and importantly acknowledge that APNs "must demonstrate the ability to independently evaluate and improve the quality of care provided" (p. 4).
Although the competency assessment process is well documented, the concept of professional role development in advanced practice nursing is less clearly defined. Holt (1987) addressed the "Developmental Stages of the Clinical Nurse Specialist," which portrayed the journey of new APN graduates into experienced practitioners as framed in the traditional components of the Clinical Nurse Specialist role. Hixon (1996) applied the work of Benner (1984) to delineate APN characteristics of performance from novice to expert practitioner on the basis of the author's personal experience. She used the term "professional socialization" to describe the "process by which an individual acquires the skills, content, and sense of occupational identity characteristic of that profession" (p. 34).
The role of APN case managers has been described in the literature. A model advocating for APNs as case managers (Taylor, 1999) lists competencies and skills of an advanced practitioner that enhance providing effective case management. This model, however, was developed for an inpatient setting and does not address skill acquisition or peer review. Likewise, Naylor et al. (2004) demonstrated the utility of a community based transitional care model using APNs as case managers. Although measurable outcomes were notable with this APN intervention, an examination of professional development in this practice was not described. Stanton, Swanson, Sherrod, and Packa (2005) recognized the need for the advanced practice role in some settings of nurse case management as client needs became more diverse and complex.
As previously described, the clinicians in the CBCM department were strongly grounded in the CPDM professional practice model. In an article generated from analysis of that practice model, Bobay, Gentile, and Hagle (2009) note that it "is the nurses' intense involvement in reflective practice that allows them to make judgments and take action in clinical situations" (p. 49). The potential relationship between reflection and professional development is also identified. Ongoing literature review over the course of the team's work continued to validate the use of reflective practice methodology in constructing an Advanced Practice Nurse Case Manager (APNCM) professional development framework.
First described by Schon (1983), reflective practice was conceived as a process for enhanced learning within the field of education. Benner (1984) began the use of "exemplars" in nursing practice as a means of observing and collecting behaviors. She defines an exemplar as "...an example that conveys more than one intent, meaning, function, or outcome and can easily be compared or translated to other clinical situations whose objective characteristics might be quite different" (p. 293).
Esterhuizen and Freshwater (2008) examined the role of reflective practice in the nursing field and believe that reflection can be used to improve, as well as describe, nursing practice. The work of both McClelland and Fish (as cited in Esterhuizen and Freshwater, 2008) illustrates awareness of practice as an iceberg in which only the "doing" is visible above the surface. The deeper aspects of practical experience (i.e., expectations, values, and assumptions) that lie below the surface may be uncovered through reflection.
Freshwater (2008) further states that "....effective reflection on practice can lead to more conscious, deliberative, and intentional interventions" and that "...reflection on beliefs, values, and norms offers the opportunity to examine, articulate, and generate local theories and philosophies of care..." (p. 11). With this support from the literature, the project team committed to using reflective practice methodology through written clinical narratives to examine and describe professional growth and development in the APNCM role.
A qualitative method with analysis of content to determine themes or patterns was used to understand the phenomenon of APNCM practice development. Each project team member wrote several narrative accounts reflecting upon encounters that had occurred recently in their practice. The focus of a narrative ranged from addressing a client concern to coordinating communication and planning among multiple providers. Because the practice is so varied, narratives were written to illustrate different situations. At the time of initial narrative writing, two team members were in their first year of practice as case managers, while the other nurses had practiced as case managers for several years.
Each narrative was read independently by team members with a focus on identifying the presence of case management behaviors. The project team as a group discussed case management behaviors they had identified, came to consensus, and labeled each behavior with a descriptor. The pertinent quotations from the narrative were recorded with the descriptors.
Similar behaviors emerged as the number of narratives reviewed increased. When a behavior was the same or very similar to another behavior, the quotation was added to the previously recorded behavior. If a new and unique behavior was recognized, it was labeled and recorded as a separate descriptor.
When practice behaviors had been identified in 24 narratives, the listing of descriptors was analyzed. Descriptors labeled similarly were reviewed with the supportive quotations to determine whether they were unique behaviors or closely related behaviors. A single descriptor statement was written to incorporate behaviors seen as closely related, illustrated in Table 1. This process, known as development of thick descriptors (Burke & Farrell, 1999), resulted in a listing of 124 descriptors of community-based nurse case management practice.
Grouping like behaviors together resulted in three broad practice classifications or domains: relationship/partnership, clinical knowledge and decision making, and coordination and collaboration.
The relationship/partnership domain focuses on the connection developed between the client and nurse case manager. Often, the relationships chronically ill clients have with providers are based on interactions in the office or inpatient setting. The CBCM nurse case manager's relationship, developed within the client's home, recognizes and appreciates the effect that the client's environment and support system has upon their health management. Partnership is developed when power is shared equitably and the client exercises autonomy in decision making (Hook, 2006). A case manager's development of expertise in this domain influences achievement of positive outcomes with the client population.
The clinical knowledge and decision making domain reflects development of the NCM's expertise in assisting the client to recognize opportunities for improvement of their health. Along this continuum, the NCM's ability to determine the salience of factors within the situation and their relative importance progresses. Nurse case manager behaviors move from a focus on standard guidelines and tools as the basis of care to intuitive recognition of the situation with attention to the most pertinent aspects.
The third domain of CBCM practice, coordination/collaboration, involves navigating the system of providers and resources needed to manage multiple chronic illnesses. Although each client's needs and situation is unique, they have often experienced fragmented care. Recognizing the gaps that are present and role modeling methods to close them are the essence of this domain.
Further descriptor analysis concluded that three stages of APN practice were consistently seen: Competent, Proficient, and Expert. The experience of the NCMs on the project team was that a clear progression occurs in the continuum of practice from Competent to Expert. Analysis of the narratives validated what the NCMs had observed in themselves and each other. The breadth of parameters considered in decision making evolves, as does the ability to recognize and utilize leverage points to influence client behaviors and/or system response. The descriptors of each domain were grouped by stage. Tables 2 and 3 illustrate a sampling of related descriptors and their supportive narrative statements along the three-stage continuum of practice.
More descriptors are present in the Proficient stage than in either the Competent or Expert stage. Since early role development is based upon standards, and expert development is more intuitive, it is logical that fewer unique descriptors are present at the Competent and Expert stages. Although there is a flow of descriptors between stages, there was not an exact matching of descriptors across stages.
All descriptors identified in the written narratives were incorporated into the framework. Practice expectations for a competent practitioner are clearly described, while distinctions between competent, proficient and expert practice are delineated. The entire framework is shown in Table 4.
The three domains recognized within CBCM practice are strongly related to domains identified in previous reflective practice work with other nursing roles. The CBCM Relationship/Partnership domain is rooted in the domain of Caring, which is identified by Benner (1984) in her original work with nurses in an intensive care unit setting and in the Caring domain of the Clinical Practice Development for acute care nurses described by Haag-Heitman (1999). The behaviors within the Relationship/Partnership domain possess significant breadth and depth as befits practice that occurs within a client's personal surroundings and often extends over many months.
Benner's domains of "Teaching-Coaching," "Diagnostic and Patient Monitoring," "Effective Management of Rapidly Changing Situations," and "Administering and Monitoring Therapeutic Interventions and Regimens" (1984) have been woven into a single CBCM domain. The Clinical Knowledge and Decision Making domain within CBCM is titled consistently with that of the CPDM model (Haag-Heitman, 1999). Although Benner's threads remain as components within this CBCM domain, the characteristic interventions and time perspective in which they occur vary significantly with the difference in client needs and the amount of control the NCM has within the community setting.
The CBCM domain of Coordination/Collaboration is expansive in comparison to Benner's original (1984) domain of "Monitoring and Ensuring the Quality of Health Care Practices" and CPDM's "Collaboration" (Haag-Heitman, 1999). The practice setting and the complexity of client needs necessitate a broader description of NCM behaviors.
The CBCM reflective practice framework, with three stages of practice development, differs from other nursing reflective practice models that have identified four or five stages (Benner, 1984; Haag-Heitman, 1999). Since all NCMs in this practice were experienced advanced practice nurses when they began working in the NCM role, they brought considerable knowledge and expertise to their new role. Therefore, the novice level of practice development was not present as it is when practitioners have a limited range of experiences.
Practice development occurs as a continuum with changes occurring in patterns. The descriptors seen in CBCM practice logically divided into three practice levels. It was common that narratives exhibited descriptors from more than one stage of practice as expertise progresses at different rates in the different domains.
Using reflection to identify practice behaviors is time consuming and complex. To expedite the framework development, the team wrote descriptors for content areas they expected to find. Because evidence for all descriptors was not found in further review of the narratives, the project team reverted to analysis of narratives to generate descriptors. Furthermore, the team noted that Benner (1984) clearly cautioned against "hasty system builders" (p. xxii). She considered such solutions to limit understanding and stated additionally that "to understand behavior, therefore, one must look for it in its larger context" (p. 39).
As the framework development progressed, ways to apply it in daily NCM practice became clearer. Specific practical uses have included staff orientation, mentoring, ongoing professional learning, and advancing practice development.
The initial application of the framework occurred in orientation. All NCMs in the CBCM department are required to be experienced APNs. Typically, APNs have developed expertise in a specific practice area. Transitioning to the role of NCM has been a challenge for new staff. Often, the move to a community setting has been an additional change.
During orientation, preceptors shared NCM narratives used in the framework development with the orientee. This activity helped normalize feelings about role change as the narratives illustrated comparable challenges faced by other NCMs. It also served as a platform to facilitate discussion of behaviors along a growth continuum. To promote the practice of reflective writing, the orientee was asked to write a narrative. The narrative provided specific evidence of NCM competency, as well as additional insights into the thoughts driving clinical decision making. At the conclusion of orientation, the preceptors easily applied the framework's domains and behavioral language in framing the final orientation evaluation. The framework provided effective language to capture the new NCM's abilities and to link practice achievement with specific descriptors.
Providing opportunities for useful and effective peer evaluation is a struggle in all areas of nursing (Hicks, 2005), particularly in advanced practice roles (Crumbie & Kyle, 2006). Presentation of an annual case review with focus on problem solving and care plan refinement had served as the CBCM peer review process. Peers provided feedback using a written competency tool adapted from the American Nurses Association's Nursing Scope and Standards of Practice (American Nurses Association, 2004) and CMSA's Standards for Practice for Case Managers (CMSA, 2002). Since the case reviews were structured to generate pertinent strategies and solutions for working with the client, the emphasis was not on NCM practice. The narrative writing experiences that reflected upon practice, and the newly developed practice framework, challenged the group to develop a more authentic peer evaluation process.
A shared governance decision was made to use a written narrative, illustrating an episode of client care, as the focal point for peer review. This design shifted the emphasis of discussion to NCM practice and guided the dialogue toward domains of practice and nursing behaviors. A venue for capturing those deeper elements of practice that lie below the surface of one's awareness, as described by Esterhuizen and Freshwater (2008), was provided with this reflective process. Staff used the framework to guide feedback on the basis of practice descriptors. The continuum of practice inherent in the framework provided opportunity for specific feedback regarding areas for growth as well as commentary regarding areas of mastery. The design of this new process was grounded in an environment of openness, sharing, and group learning. Evaluation affirmed the merit of reflective practice and led to further refinement of the process.
Implementing the framework within the department involved a magnitude of change greater than anticipated. A shared understanding of the reflective practice concept and the framework, as well as a commitment to authentic appraisal, was required to successfully integrate the framework into examination of nursing practice and peer review. Close examination and discussion of one's practice can be disconcerting in a group setting and requires a culture of trust and openness. Staff needed to sensitively deliver concrete, specific feedback, while also being open and willing to receive such evaluation. A shift in mindset developed from that of a case review to that of developing practice as each NCM took a turn in presenting a narrative story.
Since the practice framework was developed by a subset of department staff over a period of time, implementing the new format involved an additional time investment for other staff members. A more inclusive process involving the participation of all staff members may have resulted in an easier assimilation of the framework. Reflective writing is time intensive, as it requires self-examination, critical thinking, and analysis. Staff was also challenged to integrate the framework language with the existing competency tool.
Overall, staff members agree that while it is time intensive, reflective writing has unveiled the richness and depth of NCM practice. As one colleague observed, "It was helpful to write this narrative because I think I had an 'AHA' that I didn't have when I started working with this client." Such insights have served to cultivate practice development and to identify examples of nursing excellence to be celebrated.
The Advanced Practice Nurse Case Manager Reflective Practice Framework has generated interest from APNs, nurse leaders, and other practice disciplines. Advanced practice nurses and other practitioners have reviewed the model and sought consultation regarding the development of their own reflective practice models. As additional narratives are analyzed, the framework is expected to further develop. This growth will increase the body of APN knowledge about community based case management behaviors and expertise.
The development of this reflective practice framework has resulted in greater recognition of the depth of knowledge and skills involved in community-based case management. Reflective writing has enhanced both orientation and peer review processes, as it reveals practice development over the course of time. The framework may be applicable to the practice of other APN case managers in community settings or serve as a guide for development of a tool for other nontraditional nursing roles.
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advanced nursing practice; advanced practice nursing; case management; peer-review; reflective practice
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