Evaluations of Clinical Learning in a Managed Care Environment

Evaluations of Clinical Learning in a Managed Care J

Envzronment

Elizabeth P. Howard, RN, PhD, CS, ACNP, and Sharon Steinberg, RN, MS, CS

TOPIC. Clinical learning in a managed-care environment. PURPOSE. To obtain evaluative data about clinical learning experiences for graduate nursing students based on the domains of competence for successful practice in managed-care organizations. METHODS. A survey of 42 nurses (20 graduate students, 22 nurse practitioner preceptors) self- reported on two questionnaires. FINDINGS. Both the students and preceptors reported that there were learning opportunities for research utilization, the development of clinical competence, the identification of group dynamics, the development of leadership skills. In addition, the respondents reported learning opportunities to examine the financial impact on healthcare delivery and clinician decision making. The area of ethics and its impact on clinical decision making is an apparent void, as reported by the respondents. CONCLUSIONS. A managed care environment does provide an effective learning environment for nurse practitioner students. Search terms: Advanced practice nursing education, clinical education, education evaluation, graduate nurse practitioner students

Elizabeth P. Houmrd, R N , PhD, CS, ACNP, is Associate Professor of Nursing, Northeastern University, Bouve College of Health Sciences, School of Nursing, and Sharon Steinberg, R N , M S , CS, is Director, Nursing Teaching Program, Department of Ambulatory Care and Prevention, Harvard Medical SchoollHarvard Pilgrim Health Care, Cambridge, M A .

o v e r the past decade, there have been dramatic changes in health care. Healthcare professionals have experienced the growth of integrated delivery systems and managed care organizations (MCOs). Advanced practice nurses and other health professionals are being pres- sured to deliver quality, cost effective patient care within fixed budgets and, in effect, to be managers of the healthcare system. As a result of these changes, colleges and schools of nursing must ensure that the academic and clinical milieu prepares new advanced practice nurses to function in these systems and offers direct experience in the types of practices and problems they will encounter in their careers (Lurie, 1996).

The master’s degree curriculum for preparing advanced practice nurses (APNs) at colleges and schools of nursing includes a theoretical or didactic portion and a clinical practice component. Typically, faculty and students have sought clinical placements in traditional settings, such as acute care hospitals, school health services and outpatient clinics. Today, faculty must examine the potential of MCOs and integrated delivery systems to provide significant clinical learning experiences. These newer systems offer advanced practice nursing students valuable opportunities to develop their clinical skills, focus on evidence based clinical guidelines and health outcomes, and actively manage patient care across the continuum from hospital to home (Steinberg, 2000).

As the clinical education environment shifts to settings where care is actively managed, nursing faculty members need to develop and implement newer methods to assess the efficacy of these settings in providing knowledge, competence, and skills necessary for effective clinical practice in future times.

12 Nursing Forum Volume 37, No. 1, January-March, 2002

This article reports on a small, initial evaluation of graduate students’ clinical learning experiences in one managed care environment. Given the current healthcare environment and the impact of managed care on that environment, nurse practitioners need to be prepared to function effectively as advanced clinicians. Initially, the authors compared the core cumculum content for advanced practice nurses to the clinical competencies needed by healthcare providers to function effectively in MCOs. Th~s comparative analysis provided a foundation with which to evaluate the clinical learning opportunities in one setting operating as a managed care organization. Table 1 compares the Graduate Core Curriculum Con- tent for advanced practice nursing put forth by the American Association of Colleges of Nursing ([AACNI, 1996) with the proposed competencies for healthcare providers working in managed care environments developed by the Council on Graduate Medical Education ([CGME], 1997). Both reports identify five complemen- tary areas of competency:

w Etlucs w Iiesearch/quality measurement and improvement

Financing, organization of health care a Development of professional role and patient

provider rela tionship / leadership w Health promotion and disease prevention/competen-

cies relevant to primary care

While this study focuses primarily on clinical learning experiences, it is important to stress that the didactic content of an advanced nursing practice curriculum also needs to address these competencies in order to provide the foundation for the clinical learning experiences.

Review of the Literature

Clinical Learning

Ethics. Ethical conflicts are a concern for clinicians working in all healthcare settings, including managed

Table 1. Comparison of Core Curriculum Content

American Association of Colleges of Nursing Medical Education Graduate Core Curriculum Content care Providers in Managed

Council on Graduate

Competencies for Health-

Care Environments

Ethics Research

Ethics Quality measurement and iinprovemen t

Financing, organizalion Financing, organization of of health care health care Proftsional role development leadership provider rela tionships Health promotion and disease care primary prevention

Development of patient

Competencies relevant to

care environments. Advances in medical technology continue to generate novel ethical dilemmas for healthcare providers. As the setting, finances, and resources for healthcare delivery change, clinicians face additional conflicts as they work to provide lugh quality health care for all individuals. A graduate curriculum for advanced practice nurses in managed care ethics goes beyond the traditional ethical issues formally defined as nursing ethics. These issues include resource allocation decisions, individual- vs. population-based responsibilities, trust and the clinician/patient relationship, professionalism and patient advocacy, and tensions between business ethics and professional ethics (Bunkers, 2000; Marsee, 2000; Ulrich, 2001).

ResearcWQuality measurement and improvement. Managed care organizations are interested in using evidence based clinical decision making to provide therapeutic intervention that is effective and of value. Clini- cians are expected to keep track of the patients they see, the outcomes of care, and interpret and apply ths data to the broader health of specific patient populations. Clini- cians need to be familiar with practice guidelines and continuous quality improvement methods. Increasingly, it is a common expectation that scientific literature bc

Nursing Forum Volume 37, No. 1, January-March, 2002 13

~

Evaluations of Clinical Learning in a Managed Care Environment

used to evaluate the appropriateness and effectiveness of therapies and to develop clinical guidelines.

Graduate nursing students benefit from working in healthcare delivery systems that focus on outcome mea- sures, particularly cost efficiency and quality care. Prac- tice guidelines and a research based practice is not new to the advanced practice role, but evaluating appropriate utilization of resources is a new component of the nursing role. Students need to learn and experience this as- pect of clinical decision making, selecting options that provide the best care while thoughtfully taking account of cost considerations (Bell & Proctor, 1998; Brown, 1998; Bunkers, 2000).

Financing, organization of health care. Knowledge of organizations, delivery systems for health care, health policy and financing are key elements to prepare APNs for work in managed care environments (PEW, 1995). Advanced practice nurses need to know about the megasystem of health care, and to understand how financing and delivery systems affect access to and delivery of care at the local and regional levels, decision making of patients and clinicians, the health of the community, and the implications for resource allocations in a defined population. They also need to develop skills necessary to deliver cost effective interventions and know how to make appropriate resource allocation decisions (Berger et al., 1996).

Professional role developmentldevelopment of patient provider relationships; leadership. Administra- tors in managed care environments seek clinicians with effective leadership skills. Clinicians in staff model HMOs and multispecialty group practices where care is actively managed work in interdisciplinary settings; thus, knowledge of expanded teamwork, group dynamics, and organizational behavior is essential. Collabora- tive practice with other health professionals is integral to these settings because the care of large groups of patients requires a team of multiple disciplines to offer integrated healthcare services across the continuum of care.

Advanced practice nurses are expected to assume a leadership role in their professional positions. Cultivat-

ing leadership skills in both the theoretical and clinical component of the program through the processes of role modeling and mentoring helps solidify this desirable characteristic in graduates. For all graduate students, functioning in the role of the advanced practice nurse is new. Consequently, role socialization becomes an initial objective within the clinical learning experience, with the preceptor serving as the primary role model for the direct provision of care. The advanced practice, graduate nursing student also needs a role model who is an active participant in professional organizations. Gradu- ate nursing students observe how nurse practitioners in- tegrate this role component into their practice and how favorable outcomes result from professional participation. Legislative changes that affect health care and other influences from politically active groups demonstrate to the students the value in pursuing a professional leadership role (Neuman, Newman, & Holder, 2000).

Health promotion and disease preventiodcompe- tencies relevant to primary care. Most graduate nursing students pursue graduate education to expand their practice base and to learn to provide advanced nursing care to diverse populations with varying health problems. Their clinical experiences need to span the continuum of healthcare services and allow opportunity for the development of reflective skills (Brown, 1998; Glaze, 2001; Murphy-Ende, 2002). From the wellness perspec- tive, a focus on health promotion and disease prevention is a valuable clinical learning experience. Graduate nursing students develop competence in the management of patient illness and learn to evaluate patients’ response to therapeutic interventions. In the MCO setting, graduate nursing students observe and intervene at one or multiple levels as patients transition from home to hospital, to extended care services, and finally to a return to the home environment. These experiences may provide students with learning opportunities that span the wellness- illness continuum and allow for valuable interactions with patients and their families throughout this continuum (Bellack, Graber, ONeil, Musham, & Lancaster, 1999).


Evaluation of Clinical Learning

The clinical component of any nursing program pre- sents challenges to faculty evaluators due to the varied nature of the clinical learning environment and the use of preceptors. The Goal-Based Evaluation Model (House, 1980) provides the structure and guidelines for a system- atic approach to the evaluation of clinical learning. Ap- plying this model involves stated goals of the clinical learning experience and the collection of data to deter- mine whether the goals have been met (House). For graduate students in managed care environments, the AACN (1996) core curriculum content and the CGME (1997) competencies for healthcare providers working in managed care environments provide the context for the educational goals in clinical learning.

Optimal evaluation of clinical learning reflects the ap- proaches and methodology utilized. If a preceptor model is utilized for clinical instruction, the program evaluation needs to include both students and preceptors.

The major goal of this project was to obtain preliminary, evaluative data about the clinical learning experiences for graduate nursing students in one managed care organization. Specifically, the co-investigators im- plemented a goal-based evaluation model through the use of self-administered surveys to collect data from students and their preceptors on the domains of competence for successful practice within settings where care is actively managed. The outcomes from this evaluation may be used to improve graduate nursing cur- ricula and their associated clinical learning experiences. The graduate core content for advanced practice nurses and the competencies for healthcare providers in managed care served as the organizing framework for the evaluation.

Research Questions

Utilizing the Goal-Based Evaluation Model, the fol- lowing five research questions were addressed to examine the clinical learning experiences for graduate nursing students in managed care organizations:

1. Are students exposed to ethical dilemmas relevant to managed care?

2. What type of learning experiences do graduate nursing students have that examine financing and the organization of health care?

3. Do students have learning opportunities incorporating research methods appropriate for quality measurement and improvement?

4. Are there learning opportunities addressing professional role development and leadership?

5. Do the learning opportunities develop competencies related to health promotion and disease prevention?

Methods

Sample

Graduate nursing students who completed the majority of their clinical experiences at one large HMO in the Northeast region of the country served as the population from which the sample was drawn. The co-investigators contacted the clinical faculty of the graduate students, representing four graduate schools of nursing. These faculty assisted the co-investigators in the data collection process by distributing the questionnaires. The students returned the questionnaires using a stamped, addressed envelope. The administrative per- sonnel of the HMO provided the co-investigators with a list of nurse practitioners who served as preceptors for the graduate students. Using interoffice mail, the co-investigators distributed the preceptor surveys with a return envelope to 40 preceptors. Anonymity of all respondents was guaranteed in a cover letter that accompanied the questionnaires.

Twenty graduate nursing students and 22 preceptors returned completed questionnaires (N = 42). This repre- sents a 76% and 55 % return rate, respectively. Among the graduate nursing students, the average number of years of professional nursing experience was 6.7 years (SD = 7.0). The preceptors worked in various primary care and specialty care areas.



Instruments

The co-investigators developed two parallel survey tools to collect information on the students’ and preceptors’ evaluation of clinical learning experiences in a managed-care setting. The tools contain both open- ended and closed-ended questions to collect qualitative and quantitative data. The graduate core curriculum content for advanced practice nurses proposed by the AACN (1996) and the competencies for healthcare providers in managed care environments served as the organizing framework for the questionnaires. Content validity was obtained through peer review. Two other nursing faculty members were given the survey tools and the comparison table for the AACN core curriculum content and the CGME competencies for healthcare providers in managed care environments. They were asked to evaluate whether the survey questions ade- quately addressed the content in the comparison table. Since the smeys were developed for this project, there were no previous reliability estimates. Given the small sample size and the homogeneity of the obtained sample, reliability estimates were not computed for this pilot project.

Data Analysis

The SPSS software program was used to analyze the data. Descriptive statistics including frequencies and percentages were calculated for all quantitative responses. Qualitative F+ sponses were recorded and analyzed manually with a search for common terms and themes. Validation of the qualitative analysis was obtained through two additional independent reviews completed by I.esearch assistanis

Results

Research Question 1: Are students exposed to ethical dilemmas relevant to managed care?

Among the 20 graduate student respondents, 16 reported they did not have to address an ethical dilemma

as a clinician in a MCO. Four respondents stated they did address ethical dilemmas in the MCO. The students had an opportunity to describe any form of ethical dilemma experienced in the practicum setting.

The ethical dilemmas described by the four mpondents addressed such diverse issues as trying to protect the rights of a pregnant teenager whose mother insisted on being present during office visits; trying to decide which patient to spend extra time with, given the time pressure and de- mands of the work setting; and how to decide when time is limited-whether to treat a patient for a present com- plaint or to address a chronic problem. Preceptors also were asked if their students had to address an ethical dilemma as a clinician in a HMO. Two preceptors re- sponded they did have to address ethical dilemmas with their students in the Hh40 but did not describe the details of the dilemma. The remaining 20 preceptors reported the students were not exposed to any ethical dilemmas.

Research Question 2: What type of learning experiences do graduate nursing students have that examine financing and the organization of health care?

Specifically, this question addressed the extent to which students had exposure to the financial impact of health care on: access to health care; the healthcare delivery system; patient decision making: and nurse practitioner decision making. Figure 1 summarizes the student and preceptor responses. The majority of student and preceptor respondents reported the clinical experience provided learning opportunities that focused on financing and organization of healthcare. Nurse practitioner decision making was the most frequently reported experience within the area of finance reported by both preceptors and graduate nursing students.

Research Question 3: Do students have learning opportunities incorporating research methods appropriate for quality measurement and improvement?

Table 2 summarizes the student and preceptor assessment of learning opportunities that address research and


Figure 1. Financing and Organization of Health Care 80,

70

60

50

40

30

20

10 n "

Access to Health Patient NP Health Care Decision Decision Care Delivery Making Making

% students % perceptors

quality measurement issues. Both students and preceptors acknowledged learning opportunities that incorpo- rate research utilization. A large percentage of preceptors reported experience with implementation of clinical outcomes projects; however, only 5% of the student respondents concurred with this assessment. Unfortunately, while given the opportunity to respond to an open- ended question, the preceptgrs did not elaborate and describe their projects.

Table 2. Research Methods and Quality Measurement

Students Preceptors Clinical Experience N(%) N(%)

Participate in research 1(5) l(4.5)

m Development of clinical 1 (5) 2 (9)

Implementation of clinical 1(5) 10 (45)

studies Research utilization 10 (50) 14 (64)

outcomes projects

Research Question 4: Are there learning opportunities addressing professional role development and leadership?

This question examined learning opportunities that addressed professional role development and leaderslup. Leadership skills, including knowledge of multidisci- plinary teams, group dynamics, and organizational behavior, are fundamental in managed care environments. For a new AI", the primary goal may be to attain competence in the advanced practice role rather than hylng to assume a leadership role. Graduate students, however, can develop leadership skills from the theoretical and clinical components of a graduate program through the direction of a role model and mentor.

A preceptor not only serves as a role model to graduate students for direct provision of care, but also may demonstrate the importance of being involved with legislative changes and being politically active. These roles will be sigruficant in developing their professional leadership role.

Assuming leadership roles in the healthcare arena is integral to the advanced practice nurse's professional po- sition. These skills need to be developed at the graduate nursing level, with preceptors serving as role models. Table 3 summarizes the student and preceptor responses to this question. A large proportion of students and preceptors reported exposure to experiences related to group dynamics. In addition, 40% of the students and 41% of the preceptors reported the opportunity to develop leadership skills within the clinical experience.

Research Question 5 Do the learning Opportunities develop competencies related to health promotion and disease prevention?

This question included health promotion and disease prevention. Both the AACN Graduate Core Cumdum (1996) and the Competency in Managed Care (1997) identdy the need for clinical experiences with health promotion and disease prevention. The clinical experiences need to focus on the wellness-illness continuum. De- pending on the structure of the learning experience



Table 3. Professional Role Development


rn Identsfy group dynanucs 16 (80) 14 (64) Develop leadership skills 8 (40) 9 (41)

rn Utilize database for 1(5) l(4.5)

rn Utihze database for 1(5) l(4.5) monitoring costs

within an MCOs environment, graduate students may have an opportunity to observe and assist as patients make the transition from home to hospital, to extended care facilities, and the return home. This experience al- lows the student learning opportunities that extend over the wellness-illness continuum. Table 4 summarizes the responses to this question. Overall, both students and preceptors report clinical learning opportunities that re- late to health promotion, disease prevention, and the development of clinical competence.

Discussion

The area of ethics and its impact on clinical decision making is an apparent void in the clinical education of the advanced practice nursing student working in an MCO. Both students and preceptors report limited opportunities to address ethical dilemmas in the work setting. It seems unlikely that few ethical dilemmas are en- countered. Rather, there may be a limited perception or recognition when the student or clinician actually is involved in the ethical decision-making process. The integration of case methodology in the didactic component of the educational program may serve to heighten students’ awareness of ethical dilemmas present in various clinical situations. Advanced practice graduate nursing students may be encouraged to present cases on patients they have cared for during their clinical experiences and to include the ethical elements similarly as they focus on the pathophysiologic processes and interventional strategies.

Table 4. Health Promotion Clinical Competence


Experiences encompass 18 (90) 19 (85) the wellness-illness continuum

m Care of specific groups 14 (70) 13 (60) Experiences address 13 (65) 14 (66) health promotion and

One-half of the students and preceptors reported the clinical experiences provided the opportunity to examine the financial impact on patient access to health care and patient decision making. The majority of students and preceptors reported opportunity to examine the financial impact on healthcare delivery and clinician decision making. These results support the goal of preparing for practice in future times.

One educational outcome for advanced practice nurses is the ability to serve as a participating member on a research study, inclusive of quality assurance projects and measurement of outcomes studies. Both students and preceptors acknowledge opportunities for research utilization. However, students reported minimal experiences with participation in research studies and the development and implementation of clinical outcomes projects. Time pressures in the clinical practice arena may affect this component of educational prepara- tion. Without external funding to provide clinicians with release time from their practice commitments, research often is viewed as a luxury, usually attempted only when all other work is completed. Graduate nursing faculty appear to be aware of this limitation within the clinical practicum experience. Many schools and colleges have adopted a ”research practicum” model in which the APN student is paired with clixucians conducting an ac- tual research study. In these practica, the students work as research assistants and are able to focus their efforts solely on the application of the scientific process.


Both groups of respondents reported there were learning experiences that provided for the identification of group dynamics and the development of leadership skills. Reportedly, there was minimal opportunity for the utilization of databases to monitor costs and productivity. This administrative component needs to be examined carefully. One expects that managers would hold ultimate responsibility for this activ- ity; there are direct implications, however, for the clinicians who are the direct providers of care. Perhaps there needs to be a dialogue among MCO administra- tors, clinicians, and faculty to discuss and delineate the level of knowledge and competence essential for clinicians regarding the utilization of databases for monitoring costs and productivity.

Students and preceptors reported learning opportunities to develop clinical competence, and these experiences encompassed the wellness-illness continuum. Ap- parently, these non-traditional “teaching” institutions are effective in providing graduate nursing students with the essential clinical skills to develop as competent advanced practice nurses.

Limitations

In this study, the authors did not examine attitudes toward managed care organizations as a healthcare delivery system. These attitudes may influence and have an impact on the clinical learning potential within the practicum setting. In one study of medical education and managed care, Skootsky et al. (1999) found physician trainees’ personal opinions toward managed care were mostly negative. Nursing faculty remains an important factor in the learning equation for APNs. Future studies should examine the faculty attitudes, opinions, and experiences regarding managed care organizations as a clinical learning environment for APNs. These results may point to the need for faculty-development programs aimed at maximizing the learning opportunities for graduate nursing students as well as strategies for effective didactic instructions that complement the clinical environment.

Conclusions

Managed care organizations continue to have a major role in educating health professionals for future roles in healthcare delivery systems. This pilot study provided evidence that managed care organizations do provide learning opportunities that are essential for the education of advanced practice nurses. Both preceptors and students acknowledged learning opportunities in the areas of clinical competence, leadership, group dynamics, finances and health care cost, and research utilization. While this small study provided some preliminary data on the evaluation of clinical learning in MCOs, there is a need for formative evaluation models to continuously monitor the quality of learning experiences for advanced practice nurses in these settings. Incorporating a larger sample size, providing multiple assessment points for feedback, and the use of focused group discussions may serve to provide a comprehensive, continuous evaluation of clinical learning for nurse practitioner students in managed care organizations.

Author contact [email protected]

References

American Association of Colleges of Nursing. (19%). The essentials of master’s education for advanced practice nursing. Washington, Dc: Author.

Bell, M., & Procter, S.(1998). Developing nurse practitioners to develop practice: The experiences of nurses working on a nursing development unit. Journal of nursing management, 6,61-69.

Bellack, J., Graber, D., ONeil, E., Musham, C., & Lancaster, C.(1999). Curriculum trends in nurse practitioner programs: current and ideal. Journal of Professional Nursing, 15,15-27.

Berger, A., Eilers, J., Pattrin, I., Rolf-Fixley, M., Pfeifer, B., Rogge, J., Wheeler, L., Bergstron, N., & Heck, C. (1996). Advanced practice roles for nurses in tomorrow’s healthcare systems. Clinical Nurse Specialist, 10,250-255.

Brown, S. (1998). A framework for advanced practice nursing. Journal of Professional Nursing, 14,157- 164.

Bunkers, S. (2000). The nurse scholar of the 21stcentury. Nursing Science Quarterly, 13, 116-123.



Council on Graduate Medical Education. (1997). Preparing learners for practice in a managed care environment. Washington, Dc: US. Depart- ment of Health and Human Services.

Glaze, J. (2001). Reflection as a transforming process: Student advanced nurse practitioners' experiences of developing reflective skills as part of an MSc programme. Journal of Advanced Nursing, 34, 639-647.

House, E. (1980). Evaluating with validity. Beverly Hills, CA Sage.

Lurie, N., (1996). Preparing physicians for practice in a managed care environment. Acadwrlic Medicine, 71,1044-1049.

Lynch, E. (1974). Implications fur evaluation in an integrated curriculum in faculty-curriculum development. Part V , Unifying the curriculum-'& integrated appvoach. New York National League for Nursing.

Marsee, V. (2000). Ethical perspectives of reimbursement under eco- nomic pressures. Critical Care Nursing Clinics of North America, 22, 365 - 372.

Milton, C. (1999). Ethical codes and prinaples: The link to nursing t h e ory. Nursing Science Quarterly, 12,290-296.

Murphy-Ende, K. (2002). Advanced practice nursing: Reflections on the past, issues for the future. Oncology Nursing Forum, 29, 106-112.

Neuman, B., Newman, D., & Holder, P. (2000). Leadership- scholarship integration: Using the Neuman systems model for 21st century professional practice. Nursing Science Quarterly, 13(1), 60-63.

PEW Health Profession Commission. (1995). Health professions education and managed care: Challenges and necessary responses. Report of the Advisory Panel on Health Professions Education and Managed Care. San Francisco: Author.

Skootsky, S., Slavin, S., & Willces, M. (1999). Attitudes toward managed care and cost containment among primary care trainees at 3 train- ing sites. The American Journal of Managed Care, 5,1397-1404.

Steinberg, S. (2000). Managed care: How its affecting health care. Sigma Theta Tau Internatiml Honor Society of Nursing, Excellence in Nursing Administration, 2 , l & 3.

Ulrich, C. (2001). Need for knowledge of ethics. Journal ofNursing Scbl- arship, 33,306.

Visit ~ O ? W ? z and Nursecowl

online at

www.nursecominc.com/html/f orum.htm1

Download articles from the journal, check out upcoming conferences

and services, or call us at

800f242-6757


Documents

Evaluations of Clinical Learning in a Managed Care Environment