Case management by definition has various roles and responsibilities. It describes a type of care provided to clients that utilizes specific tools to coordinate case management services, and provides a mechanism to monitor the quality and cost of services at both the individual and patient population level. 1,2 Stanton and Packa 3 have described a model for rural case management that included role expectations for advanced practice nurses (APNs) functioning as case managers (CMs) in rural areas. The model and role description were based on a content analysis of the nursing literature in the area. However, no studies were found that investigated how APNs or other nurses practicing case management in rural communities described their role and/or role expectations. The current investigation will examine the perceptions of nurse case managers practicing in rural areas concerning their role.
Stanton and Packa 3 specified administrative, clinical, educational, and research role functions for APNs who function as rural CMs. These role functions were based on a content analysis completed by Stanton. 4 The clearest differentiation between APNs and those of baccalaureate or associates degree nurses performing case management in the rural areas was that APNs focused on patient or community aggregates, systems of disease, and outcomes management whereas nurses with basic preparation focused solely on the individual level of client care. 4 Additionally, APNs were expected to provide case management along the whole continuum of care and at all 3 levels of prevention whereas nurses practicing case management at the individual level were providing services in tertiary areas of the continuum. 3
The major point of the Stanton and Packa model 3 is that case management in a rural environment entails such extensive clinical, administrative, education, and research skills that it is recommended that CMs be prepared for this role at the advanced practice level. Rural clients produce many different considerations for CMs. Health problems for which individuals, families, and communities are at risk are increased in sparsely populated, geographically remote, rural areas. While services are more integrated under managed care, healthcare in rural areas remains a fragile web of services, limited in variety and accessibility. 5 Nurses who are expert generalists with a focus in community health and who understand the cultural characteristics of rural residents are especially valuable in the rural environment. 6
Case management in the rural environment is complex because of limited access to service; however, there are other contributing factors. A study completed by the Health Resource and Services Administration 7 examined the availability of healthcare for rural residents, particularly, those in low-income families. In addition to limited healthcare access, rural residents overall health status was lower than their urban counterparts. Other barriers also impeded access to health services. Findings from this study indicated that these barriers include:
- lack of proximity to providers,
- limited health services in the rural area,
- scarcity of physicians and other healthcare providers, and
- a decreasing number of hospitals providing emergency and acute care services in rural communities.
Limited access to preventive healthcare services in rural areas, as envisioned in Healthy People 2010, 8 appears to result in a higher incidence and degree of severity of health problems for rural residents. In summary, the nature of the rural environment has provided a framework for examining the role and role function of case managers.
Novak 9 completed a study that examined nurse CMs’ opinions and perceptions of their role. The study also delineated essential role elements for CMs. Nurses involved in the study who were asked about factors that inhibited their roles, indicated that there was uncertainty and confusion concerning the expectations of the CMs. These nurses also indicated feeling overwhelmed by the job responsibilities at times and indicated that there were competing concerns for clinical quality versus financial issues. 9 Although the nurse CMs in the Novak study worked in an urban-based regional medical center, several of these CMs dealt with clients from the rural areas. However, Novak’s study did not specifically focus on any role issues related to case management or advanced practice with vulnerable rural populations. Because of the unique characteristics of the clients and the environment, it is important that nurses who function in the environment help clarify and define the role.
The focus of the present research was to examine rural CMs’ perceptions of their role responsibilities and function. The study included CMs who work in rural hospitals, rural health centers, physicians’ practices, and rural-based home care. It also included nurses working in regional health centers that provide services to rural residents.
The aims of this study were to assess rural health nurses’ perceptions of the CM role and to determine:
- differences in role for rural versus urban CMs,
- specific problems for rural CMs,
- expectations and essential skills for rural CMs,
- CMs’ perceptions of the impact of case or disease management on patient outcomes,
- educational preparation for rural CMs, and
- whether a content analysis on basic and advanced case management functions were consistent with CMs and rural nurses’ perceptions.
This study provides a more in-depth insight into the practice skills and knowledge content required for the adequate educational preparation of nurse CMs who function in rural settings. Because of the fragile network of services available to rural populations, rural CMs need an in-depth knowledge of the special issues and considerations associated with healthcare for clients in the rural community.
Research Design and Methods
The sample for this study was a convenient sample of rural nurses with membership in several national, state, and local rural nursing organizations and institutions. Approximately 38 nurses from the rural environment participated in the study. Two of the respondents were faculty, 28 were nurses functioning in a rural hospital or clinic. Approximately 6 functioned in home care or public health. Data were collected from Spring 2000 through Spring 2001.
A modified Delphi technique was used for the study. The procedure used was based on the Novak study 9 and Nugent et. al. 10 A set of elicitation statements modified from the Novak study 9 was sent to the entire mailing list of rural nurses obtained from the Rural Nurse Organization (See Figure 1). This technique provided a reliable method for gathering anonymous, consensus opinions of a group of experts, namely nurses practicing in rural regions. The technique involved the content analysis and collating or responses that yielded prioritized judgments on each topic through successive rounds of questionnaires. Three rounds of questionnaires with elicitation statements were sent. Content analysis was used to determine most frequently occurring responses for each round. The major differences in rural versus urban case and disease management were identified. In addition, elicitation statements were placed on several Web sites where respondents could indicate their responses online. In each successive round, respondents were asked to rate the importance of items. To rate the item, the respondents indicated their perception of the level of importance on a 4-point likert-type scale. For each item a mean score was derived reflecting its prioritized degree of importance or rank. Highly ranked items were retained for subsequent rounds of administration until a consensus of agreement identifying the top 4 to 5 responses for each elicitation statement was achieved. After each round, lower ranked items were deleted so that each successive round reflected the highest ranked items from the previous round of responses.
After the data were analyzed, confirmatory and model building meetings both in person, by phone, and online were implemented to confirm results, discuss role variances, and delineate the rural community nurse CMs’ roles. Although this methodology is not as scientifically rigorous as is desired, it provided baseline data about what these rural nurses were experiencing with their own roles and how they envisioned the case manager functioning in the rural environment.
The responses to the elicitation statements from the first (N = 38) and last round (N = 32) of surveys is depicted in Table 1. All of the responses listed in each column were submitted on the first survey. These were subsequently eliminated because of their ranking in the second and third round of surveys. Those responses which are in boldface type were the final, rank-ordered choices of the final 32 respondents.
In this study, the respondents delineated role differences for rural CMs. Rural CMs are perceived to have a high level of autonomy. Respondents indicated that there is a strong emphasis on the community advocacy role in rural case management (ranked second). The nurses also identified an expert generalist role for rural CMs with a decided emphasis on the facilitator and counselor roles. Respondents indicated that nurse CMs in the rural environment must have a broad knowledge related to both formal and informal community resources.
The nurses in this study perceived that one of the most influential problems for rural CMs was transportation for both the nurses and the clients. Other issues and problems identified by respondents were the lack of health insurance and health benefits for some rural residents. Increasing healthcare costs, decreasing availability of services, and the scarcity of professionals—especially physicians and APNs—were also perceived as major issues/problems preventing effective healthcare for vulnerable rural clients.
Regarding the role changes associated with expectations of rural CMs, nurse respondents perceived that APNs in this environment should:
- have a generalist orientation,
- be able to function independently,
- be creative and flexible in their approaches to patient management,
- be adept at communication and triage via the phone, and
- be able to provide care and services across the lifespan.
The five highest ranked essential skills for rural CMs were:
- the ability to be creative in the coordination of resources,
- multidimensional nursing skills,
- excellent communication skills,
- high-caliber computer skills, and
- excellent driving skills.
When asked their perceptions of the impact of rural CMs on patient outcomes, the respondents top five responses were that:
- care was facilitated through CM advocacy;
- patients were empowered through patient education;
- patients were more involved in self-care and, therefore, were more satisfied with care;
- patient’s functional and quality outcomes were improved; and
- community resources were more effectively accessed and used to enhance clinical and financial outcomes.
Nurse respondents were asked to identify ways case management could be improved for rural clients. The top ranked responses were that rural CMs could:
- focus more on wellness and prevention,
- advocate to improve reimbursement coverage for working/nearly poor,
- strongly support and promote the use of telemedicine,
- partner with educational institutions to increase educational opportunities for rural nurses, and
- work with institutions and legislators to increase awareness of the unique characteristics of individuals, families, and rural communities.
The nurses involved in the study were asked to identify essential elements of content for the educational preparation of rural CMs. There was a plethora of responses and it was not possible to delimit these further than those delineated in Figure 2. The responses that are included were specified with the same high frequency, and the focus group felt that these topics could not be refined or consolidated further.
In addition, the nurses in the focus group were asked to respond to the role delineation for APNs developed by Stanton 4 via a content analysis (See Figure 3). Several suggested that the integration of care across the lifespan be incorporated into the clinical component and also indicated that there needed to be more emphasis on applied research and outcomes management in the research component. The resulting list has been revised to reflect a consensus of focus group members on skills specified in the role delineation. The focus group was also asked to review the role delineation for CMs functioning in the rural area without an advanced practice degree. The results of those discussions appear in role delineation included in Figure 4. The final outcome of the focus group discussions was that further research is required to determine if the role differences suggested in the literature and validated by the focus group for this study are evident in actual practice. Rural case management at both levels of practice is evolving and will need more in-depth analysis to determine real differences in the roles. However, there was consensus among all members of the focus group that the best alternative for case management in the rural setting is an APN.
There appears to be a heavy emphasis on communications skills. Respondents indicated that APNs who function as CMs in a rural setting need broader practice skills that span different levels of prevention and encompass practice with clients across the entire lifespan. In the rural setting, there is an increased emphasis on community advocacy. APNs in rural settings also need to be able to access and mobilize a broader range of formal and informal community resources in the rural environment. Nurses working in rural settings seem to feel compelled to empower patients and families through education to enhance their self-care capabilities. Indeed, a major point of the focus group discussion was that empowering patients could potentially improve health outcomes.
Ways to improve health outcomes for rural clients centered on a thorough knowledge of rural communities and characteristics of rural residents and society. Respondents in the study perceived that healthcare that spanned all three levels of prevention was paramount.
There was a surprising emphasis on technology and telemedicine. Respondents indicated that nurses need to be adept at telephone communication and triage. Respondents felt that computer skills and databases for case management practice would enhance CMs’ ability to monitor and achieve expected outcomes as well as access resources not available in their rural setting.
Nurses in the study emphasized the community and patient advocate role of the APN. They felt that the nurse needed to be politically astute and capable of mobilizing community leaders and lawmakers to facilitate better access for rural residents.
It was also apparent from the survey and focus group discussions that there is indeed a unique and distinct body of knowledge for rural nursing and rural case management. This is not a “tack on” as one respondent commented to a curriculum. It is a distinct specialty within community health and case management. Focus group participants also indicated that the practice of the rural nurse, especially the rural CM, is and should be at the advanced practice level.
However, due to poor wages, lack of educational access to graduate study by nurses living in rural communities, and the lack of emphasis and knowledge of rural health as a distinct area of practice, APNs in this area of healthcare are and probably will be scarce.
The respondents in their evaluation of the roles delineated for basic and advanced case management practice by Stanton 4 clarified that they do perceive there are two distinct levels of CM practice in the rural environment. APNs as CMs in the rural setting are not the norm, but this group believes that they should be. Respondents indicated that there should be more emphasis of graduate education for nurses in the rural environment. They also suggested that nursing professional credentialing groups consider a specialty for rural and rural case management nursing. Respondents suggested that case management services might be more widely available to remote rural residents if there was reimbursement for APNs. This might also help to improve salaries and opportunities for nurses who aspire to a career in rural case management. The respondents also noted that the costs of an APN or CM could be offset by improved clinical, financial, functional, and patient satisfaction outcomes. Studies to examine and validate this opinion were strongly supported by the focus group.
Based on the findings of this study, there are several potential conclusions:
- CM in a rural environment requires a much broader and generalist knowledge base.
- CM in a rural environment covers all levels of prevention and traverses all age groups.
- Rural case management is a distinct specialty area of practice, with a distinct knowledge base and skill level, and nurses who function as rural CMs should be prepared at the advanced practice level.
- There are definite role differences between nurses who function as CMs in rural versus urban settings.
- There are special skills unique to rural CMs at both the basic and advanced practice level.
- Rural CMs may positively affect patient outcomes.
The implication of these conclusions is that rural case management is a unique area of practice that requires different educational preparation than other APNs. There should also be further research to refine and clarify the role of rural CMs.
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