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CIN: Computers, Informatics, Nursing:
doi: 10.1097/CIN.0000000000000050
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The Development and Preliminary Effectiveness of a Nursing Case Management E-Learning Program


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Author Information

Author Affiliations: School of Nursing, College of Nursing (Dr Liu), and Department of Information Management (Dr Chu), National Taipei University of Nursing and Health Sciences; and Department of Nursing, College of Medicine, National Taiwan University and Hospital (Dr Chen), Taipei, Taiwan, Republic of China.

All of the authors have made significant contributions to the article and agree with its content. W.-I.L. received a grant (NSC99-2511-S-227-005) from the National Science Council in Taiwan. For the remaining authors, none were declared.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Kuo-Chung Chu, PhD, Department of Information Management, National Taipei University of Nursing & Health Sciences, 365, Ming Te Rd, Peitou 11219, Taipei, Taiwan, Republic of China (

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The purpose of this article was to describe the development and preliminary effectiveness of a digital case management education program. The e-learning program was built through the collaboration of a nurse educator and an informatics professor. The program was then developed according to the following steps: (1) building a visual interface, (2) scripting each unit, (3) preparing the course material and assessment tests, (4) using teaching software to record audio and video courses, (5) editing the audio recordings, (6) using instructional media or hyperlinks to finalize the interactions, (7) creating the assessment and obtaining feedback, and (8) testing the overall operation. The digital program consisted of five learning modules, self-assessment questions, learning cases, sharing experiences, and learning resources. Forty nurses participated in this study and fully completed the questionnaires both before and after the program. The knowledge and confidence levels in the experimental group were significantly higher over time than those of the comparison group. The results supported the use of educational technology to provide a more flexible and effective presentation method for continuing education programs.

Nursing personnel in Taiwan have gradually started to use case management as their care service model. However, formal preparatory nursing education does not include case management courses, and few opportunities arise for systematic continuing education using case management. Numerous case management continuing education programs provide new knowledge and skills using combined didactic lectures and case studies.1 E-learning programs are a more convenient and effective educational approach to reduce the gap between nursing education and practical implementation. Expanding e-learning applications to nursing continuing education is required to enhance the essential case management knowledge and skills of nurses. However, scant research has been conducted to determine the effectiveness of such case management e-learning programs.

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Education Needs in Case Management

Case management is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s health needs through communication and available resources to promote quality cost-effective outcomes.”2(p6) The core function and mission of case managers are to implement case management processes3,4; only people with the relevant knowledge and skills are able to implement it. Nurses need case management knowledge and skills to offer integrated services for complex needs of their serviced populations.

Numerous studies have suggested the types of knowledge and skills those are required by case managers to successfully implement case management.3–5 A study determined that the unmet case management education needs were particularly relevant to the differences between the nursing and case management processes.5 Therefore, the case management process is an important content field required for case management education.

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E-Learning for Nurses Continuing Education

E-learning refers to the use of computer technology to facilitate the educational process. It has been widely adopted as a continuing learning method for nursing staff because of benefits in achieving life learning, flexibility, enabling self-regulation, and time savings.6 E-learning provides an alternative for learning professional knowledge.7 E-learning also enhances learning outcomes and updates staff knowledge.

The evidence for e-learning could assist in conducting successful e-leaning courses and improve learning effectiveness. A meta-analysis results show that student performance in distance learning is better than that in traditional teaching and that the learning effectiveness of in-service students is particularly good.8 Hence, an e-learning model provides an alternative in versatile learning for working nurses, which might eliminate the obstacles of time and space.

Although, the e-learning market has a growth rate of 36%, failures exist.9 Numerous researchers have identified import barriers influencing the usage of e-learning in nursing staff, including computer literacy, time and flexibility, and accessibility and availability. For example, perceived ease of use and the course flexibility of e-learning courses affect learner-perceived satisfaction.10 Both technology quality and Internet quality are important factors in e-learning.11 Choosing a flexible time and less complex computer technology may help in conducting successful e-learning.

Various types of e-learning methods exist, including Web-page learning, synchronous or asynchronous learning, and CD learning. Lemaire and Greene12 compared four learning methods (traditional classrooms, video courses, Web pages, and CDs) used by medical personnel and found that the effectiveness of CD learning is significantly better than that of Web page learning. CD learning may help overcome the barriers that influence the use of e-learning because operation is easy and does not require Internet devices or a network connection, and less complex technology is necessary. Therefore, based on the current evidence, developing a standard CD course for basic concepts may be a suitable method for preparing nurses to update their essential case management knowledge and skills. However, the effectiveness of e-learning in case management, using a standard CD course, has not been thoroughly investigated. Hence, the purpose of the present study was to develop an e-learning program for case management and evaluate its preliminary effectiveness.

Descriptions of the learning effectiveness of e-learning in relevant studies can be divided into positive perceptions toward e-learning and increasing learning outcomes. The perceived advantages for learners include autonomous learning,13,14 flexible learning,15–19 easy access to courses,9–11 and increasing self-reflection.10 In addition, the measurement of the effectiveness of e-leaning consists of increasing professional knowledge9,16 and confidence in care implementation.13,19,20 These measurements are evaluated as learning effectiveness in this study.

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The Necessity for E-Learning Programs in Case Management in Taiwan

Since 2008, nursing personnel in Taiwan have been unable to renew their licenses without completing 150 credits of continuing education within 6 years. With the transformation to digital technology, developing e-learning programs that can improve the trend of technological education in nursing education has become necessary. The joint cooperation between the interdisciplinary personnel of nursing case managers and professionals of information technology to develop e-learning programs is a pioneering strategy in nursing education in Taiwan. Nursing personnel must use more flexible, timesaving, and autonomous methods to participate in continuing education because they have a busy workload. Copying a CD is easy and economical and can convey information easily. In addition, when using a CD, network access is unnecessary. These arguments support the development of case management e-learning CDs because they possess advantages that can be widely promoted.

The Taiwanese healthcare system has promoted case management as a care delivery service by nurses. In this service model, nurses require case management education to prepare professional knowledge and skills to offer or coordinate the required services for patients. However, up to 82% to 87% of the nursing personnel in Taiwan have never received continuing education courses for case management.5,21 Taiwanese nurses had limited understanding related to basic concepts and the case management process and lacked confidence in case management skills.5 Formal educational programs in nursing schools may not address educational needs. An urgent need for continuing education to prepare nurses to implement case management exists; however, few case management e-learning programs are offered for Taiwanese nurses, and no studies have examined the effectiveness of such e-learning programs as are available. Nurse educators must reduce the gap between case management practice and nursing education and accommodate the majority of nursing personnel that cannot take classes in person because of their job duties. Developing an e-learning program that can facilitate autonomous learning and improve learning effectiveness is necessary.

The development of a case management teaching strategy based on empirical evidence is a significant factor affecting the development of effective case management continuing education programs.22 Scant studies have determined the effectiveness of case management e-learning programs, and the methodology used to evaluate their effectiveness is poor: questionable reliability and the validity of the research instruments and using single groups and a lack of random assignments.23 To counteract the scarcity of existing international studies on the effectiveness of e-learning programs, adopting a randomized, double-group, pretest-posttest design is necessary to assess learning effectiveness.

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Theoretical Framework

The theoretical framework used a structure-process-outcome program quality model to guide program development, implementation, and evaluation.24 Three variables that could affect program implementation and subsequently influence nurses’ e-learning outcomes were learner education needs, program design, and organizational factors.22 These factors must be considered at the development stage. Hence, program development involved a needs assessment through a focus group to confirm nurses’ educational needs regarding case management. The educational needs were then integrated into the educational design. Finally, an evaluation was conducted to determine the preliminary learning effectiveness. The purpose of the e-learning program was to prepare nurses as case managers, focusing on essential knowledge and skills for the case management process. Hence, learning effectiveness was the main outcome measured in this study, and practice and impact on patient care were not considered in the initial e-learning development stage.

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Development of the Case Management E-Learning Program

The development of the e-learning program in this study was divided into three stages: conducting a needs assessment with a focus group, developing teaching materials, and performing a preliminary evaluation of the program. The three stages are explained as follows.

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Needs Assessment and Results

Continuing education places emphasis on the importance of the assessment of educational needs prior to the implementation of a program.19 Focus groups have been used by various scholars to assess the educational needs of nursing personnel.21 We used focus group discussions to understand the nursing-personnel requirements that occur when using a case management interactive e-learning program. This study recruited 10 current nursing personnel who had acted as case managers; had 2 or more years of practical experience with cancer patients, long-term care, psychiatry, and discharge preparation services; had assisted in the educational training of case management; or had received case management education. During recruitment, we explained the objective of the focus groups and obtained informed signed consent from participants. In addition, we also explained that the overall process would be recorded, that the data would be used only in this study, that the participants would be kept anonymous, and that their future work would not be affected. The average age of the participants was 35 years, and they had an average of 12 years of nursing experience.

The focus group discussion was held in a secure meeting room for approximately 2 hours. The order of this structural discussion was as follows: self-introduction, explanation of the research background, discussion of the themes, and conclusion of the key summaries. The participants were encouraged to express their opinions in a relaxed and comfortable manner. The investigator actively listened to the responses of the participants, promoted interactions among the members, and clarified the participants’ responses. Two questions were discussed: the need for a CD and suggestions regarding the content of the CD. The initial content of the CD was based on the standard case management process.2 We recorded the content of the overall focus group discussion by using a recording pen and converted the discussion into a transcript for data analysis.

The results were integrated with the design of the case management e-learning program. The results of the focus group were summarized as follows.

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The Necessity for a CD

The participants in the focus group all suggested that case management CDs were necessary. However, if the content from all the subjects was included, the CD would contain excessive data. The participants advised that the CD should include only general case management concepts for discussion. The content should include the basic concepts of case management, the implementation process, the role functions, problem-handling methods, role adjustments, and effects.

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Suggestions on the Items of the CD

Before the initiation of the focus group, the program was preliminarily designed around six major items based on the results of the literature review. The participants’ suggestions on various items were as follows:

1. Learning units: A video program should be used to reflect the meaning of case management. However, the lectures should not be redundant. The participants suggested reducing the program content into five units and developing lecture content to be less than 20 minutes. Adopting a method that could trigger the learners’ interests and enable them to focus on the learning units was necessary during this process.

2. Learning assessment: Designing a test for self-assessment of learning effectiveness was important and was preferred to developing a feedback mechanism.

3. Case learning: Clinical cases should be used to assist in teaching. In addition, providing practical issues to enable learners to reflect on the cases was vital. The cases should not be overly complex.

4. Experience sharing: The case managers were expected to share their experiences concerning stress adjustment and role conflicts.

5. Learning resources: Providing channels for learning resources and information was requisite.

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Development of Teaching Materials

This study cooperated with information and nursing professionals to jointly develop the e-learning program. The e-learning program was developed according to the instructional-system design processes of analysis, design, development, implementation, and assessment.20 Analysis of the development and implementation of the e-learning program, which is based on this theoretical framework, is less influenced by organizational factors. Learners are not limited by time and space and can autonomously use the e-learning programs. We developed the continuing education program based on this theoretical framework, which reflects a positive learning effectiveness.22

The integration of the needs assessment with the results of the literature review showed that the case management program should be at least 16 hours. Lectures are an important and effective teaching strategy.1 The results of other studies and the focus group supported that the main requirement for the program was the implementation of case management1 and that each learning unit should not exceed 30 minutes. The e-learning program was preliminarily designed as a 5-unit program based on case management processes. The objective of the program was to enhance the theoretical and practical knowledge of case management, as well as enhance learner skills, confidence, and preparedness for implementation.

The program content was developed, and the CD compilation was completed based on the procedures shown in Figure 1.

Figure 1
Figure 1
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1. Building a visual interface: The interactive visual interface was mainly established based on Flash (Adobe Systems, San Jose, CA). For reading clarity, the size of the Web page was adjustable.

2. Scripting each unit: Four to five program outlines were designed for each unit. A unit lecture that lasted for 12 to 15 minutes was compiled.

3. Preparing the course material using PowerPoint (Microsoft, Redmond, WA) presentations of cases and assessment tests: This included the teaching materials, PowerPoint, clinical cases, and assessment examinations essential to the program.

4. Using teaching software to record audio and video courses: The cheap and easy-to-use teaching software PowerCam (FormosaSoft, Taipei, Taiwan)23 was chosen to film the video program for each unit. Each program lasted for approximately 15 minutes.

5. Editing the audio recordings: An audio recording device was used to record the audio files related to experience sharing, and then the experience-sharing Web page was imported.

6. Using instructional media or hyperlinks to finalize the interactions: Macromedia Dreamweaver (Adobe Systems, San Jose, CA) was used to integrate and connect the various interactive Web pages. In addition, instructions for use were compiled. Buttons connecting to various interactive Web pages were provided on the start page and on the pages for various units. The instructions for use could be connected and checked. After reading the instructions, the learners could either enter the main menu or directly enter specific units.

7. Creating the assessment and obtaining feedback: Wondershare QuizCreator (WonderShare, Shenzen, Guangdong, China) was used to establish the assessment feedback. The assessment feedback could be submitted after the completion of the questions. The answers would appear during the review on the tests.

8. Testing the overall operation: The pretest version of the digital CD was completed after the study team operated, tested, and amended it.

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Evaluation of the Effectiveness of the E-Learning Program

The program evaluation adopted the double-group pretest and posttest experimental design. The experimental group received the nursing case management e-learning program developed in this study, and the control group did not receive any specific intervention. The researcher used structured questionnaires to collect data prior to the experiment and 2 weeks after the experiment. We used two scales for measurement, namely, the case management knowledge index and the case management skill scale. The scales have been previously translated or tested to prove good reliability and validity,5,21 achieving content validity index scores of 0.87 and 0.97, respectively. The Kuder-Richardson formula 20 for the knowledge index was 0.78, and the Cronbach’s α coefficient for the skills scale was .90. To improve the quality of the designed e-learning program, four satisfaction questions were developed for this study and an open area as offered to collect participants’ perceptions, comments, and issues regarding use of the e-learning program.

For participant enrollment, the experts participating in the focus group discussion were requested to invite nursing personnel to participate in this study. The nursing personnel were from various backgrounds, including long-term care, psychiatry, and cancer care. The participants were provided with a copy of the case management e-learning CD before and after the implementation of the e-learning program. The posttest was performed 2 weeks after the implementation of the e-learning program.

This study was conducted after receiving approval from the appropriate ethics committees. The participants were advised that they could withdraw from the study at any time without their potential welfare being affected and that the study would not pose them any risk. The confidentiality of their personal data would be maintained without being discussed or published. After the researcher explained the research project and answered their questions, the participants were requested to provide a signed informed consent form.

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Nursing Case Management E-Learning CD

The main menu of the CD (Figures 2 and 3) reflected the five major items as follows:

Figure 2
Figure 2
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Figure 3
Figure 3
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1. The five major learning units (Figure 4):

Figure 4
Figure 4
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 Unit 1: basic concepts for case management

 Unit 2: case management process—case screening and needs assessment

 Unit 3: case management process—development of the case management plan

 Unit 4: case management process—service implementation and coordination

 Unit 5: case management process—monitoring, evaluation, and termination

2. Learning assessment (Figure 5):

Figure 5
Figure 5
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Each unit provided 10 self-assessment questions, and each question was worth 10 points. Those who received 60 points passed the assessment. After the completion of the test, the participants could choose to review the tests or the explanations of the solutions. The test results could be printed after they entered their names.

3. Case learning:

This unit provided information regarding cases of long-term care, cancer, and psychiatry for nursing personnel with different requirements.

4. Experience sharing:

This unit shared experiences using videos of the case managers about long-term care, cancer, and psychiatry.

5. Learning resources:

Resources, such as common case management–related books, school programs, and useful case management Web sites, were provided in this unit.

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Preliminary Effectiveness Results

Analysis of the quantitative data was undertaken using the SPSS (version 19.0; IBM, Armonk, NY). The accuracy of data entry was ensured using two separate computerized versions of the data entered. All the participants completed both the time 1 and time 2 testing phases. Before each statistical test was conducted, the underlying assumptions for the tests were examined.

A total of 40 nursing personnel were enrolled as subjects, and all completed the pretest and posttest questionnaires. Most age of the participants were women (90%) and were an average age of 33 years. Most possessed a bachelor’s degree (63%), followed by a master’s degree (20%). The participants had an average of 11 years of nursing experience, and 73% had never enrolled in a case management program. Twenty nursing personnel were assigned to each group, respectively. No significant differences were noted in the basic variables between the two groups, as shown in Table 1. No significant differences were evidenced by the t test results for the pretest of case management knowledge and confidence in skills between the two groups. A high homogeneity existed between the two groups, as shown in Table 2.

Table 1
Table 1
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Table 2
Table 2
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The study sought to answer the research question: Is the case management e-learning program effective in improving nurses’ learning outcomes for knowledge and confidence in case management skills? A two-way repeated-measures analysis of variance (ANOVA) was performed on the interaction between time and groups, and a value of .05 was regarded as a significant difference. A repeated-measures ANOVA on the knowledge variable (knowledge score ranged from 0 to 18) (F1,38 = 43.9, P = .000, partial η2 = 0.536) and the confidence variable (average skill confidence score ranged from 1 to 5) (F1,38 = 5.4, P = .025, partial η2 = 0.125) revealed a significant group × time interaction. Post hoc testing showed that the total knowledge mean scores and skill confidence scores for the intervention group posttest were significantly higher than the posttest scores of the comparison group. These findings support the hypothesis that a significant difference would exist in the self-reported knowledge of case management and the self-reported performance confidence in case management skills between nurses who received the e-learning program and those who did not, as shown in Table 3.

Table 3
Table 3
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Participants’ Perceptions of the E-Learning Program

Overall, the majority of the participants had positive perceptions of the case management e-learning program. Of the participants, 85% to 95% agreed that the program was autonomous, flexible, easy to access, and increased self-reflection. However, they described certain issues and suggestions for the program. The issues arising during the e-learning included the sound volume of units 2 and 3 being too low; the PowerPoint of the units should include a picture of the lecturer; actual case examples should be linked to the learning content; the learning assessment should provide final scores and solutions after completing the test; experience sharing could be achieved by adding pictures of real work places. All these suggestions were considered to improve the program quality to finalize the case management learning CD.

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We demonstrated that the participants completed the developed e-learning program in case management, and the program improved nurses’ preparation for case management regarding knowledge and skills. The positive perceptions and learning effectiveness might derive from using the evidence for e-learning and theoretical framework to guide the program development and aid in conducting successful e-leaning courses and improve learning effectiveness.22 The preliminary effectiveness of the e-learning program was similar to the effectiveness of face-to-face continuing education in case management.21 The participants described e-learning as flexible and interesting. The design of the self-assessment questions and case learning motivated the nurses’ continued learning in the unfamiliar topic of case management. These advantages of e-learning also improve learning effectiveness.

However, we measured the participants’ self-assessed confidence levels rather than their actual performance. Additionally, to address the limited number of participants in this study, further studies with a larger sample size and compliance with the CONSORT are recommended to ensure the effectiveness of such case management e-learning programs.

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After the intervention, we found that the nursing case management e-learning program developed in this study could significantly improve the nursing personnel’s case management knowledge, confidence, and preparedness for activities. This study designed and developed an e-learning program based on the results of an integrated and systematic literature review and the needs assessment of the focus group. The e-learning teaching materials were jointly developed by nursing case management and information professionals. Nursing education personnel who were experienced in the theories and practice of case management used PowerCam to film lectures in actual classrooms to complete the filming of the video teaching materials. Information technology professionals then used software such as Flash to postproduce, compile, and design the interactive content to complete the development of the e-learning program. The preliminary effectiveness assessment results supported that the e-learning program, which was not limited by time and space, was as effective as face-to-face case management continuing education.21 The study advises to further enroll more research subjects to participate in the experiment to obtain a more complete effectiveness assessment and compare it with a face-to-face instruction assessment.

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Case management; Computer-assisted instruction; Continuing; Education; Nursing; Program development; Program evaluation

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.



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