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dissertation entitled

ROLE TRANSITIONS FOR NURSES:
FROM CAREGIVER T0 CASE MANAGER

presented by

NANCY LEE SCHMITT

has been accepted towards fulﬁllment
of the requirements for

Ph.D. degree inHigher, Adult, &

Lifelong Education

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6/01 cJCIRC/DaleDuepBSopJS

 

ROLE TRANSITIONS FOR NURSES:
FROM CARE GIVER TO CASE MANAGER

By

Nancy Lee Schmitt

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree

DOCTOR OF PHILOSOPHY
Department of Education Administration

2003

ABSTRACT

Role Transitions for Nurses:
From Caregiver To Case Manager

By

Nancy Lee Schmitt

This study describes the experiences of role transition for nurses who
made a career move from care giving to case management. How professional
nurses experience this type of career move and learn to function in new roles
provides a good example of expert to novice transitions that professionals in
many disciplines face. Findings suggest that there are factors associated with
nurses' experiences of this transition that have implications for the preparation
and support of nurses assuming roles as case managers speciﬁcally, as well as
for preparation and support of professionals in expert to novice transitions in
general.

A multi-model framework informs a scope of inquiry and analysis of
personal interview and focus group data about nurses' experiences in role
transition. Models of the role transition process, situated cognition, and
experiential learning contribute to a comprehensive conceptual scheme for
inquiry and analysis. Together these models highlight components of the
transition process, contextual inﬂuences from past and present roles, and
learning strategies that help or hinder nurses to function conﬁdently in this new
role.

Nurse case managers from three employment settings shared their

respective motivations, expectations, sources of role strain and job satisfaction,

and learning experiences associated with this role transition. Data point to
speciﬁc tensions experienced by nurses in this role transition, which include
time -task orientation, interactions and relationships, business culture and
objectives, and self-image and professional identity. Data also indicate that,
though these professionals are experienced and resourceful learners, as new
case managers, they desired and beneﬁted from guidance and support from
more experienced and knowledgeable mentors.

Recommendations for preparing and supporting nurses through this role
transition emerge from the data. These include orientation and mentoring
programs that: (a) help new case managers to assess the difference in past and
present performance expectations, (b) alert them to tensions that they may
encounter in assuming this new role, (c) inform them about relevant learning
resources and how to access them, and (d) guide them in discovering the
meaning of new experiences.

Finally, implications of this study that extend beyond this speciﬁc role
transition are presented. A performance model of continuing professional
education holds the most promise for professionals in expert to novice
transitions. This model addresses inﬂuences on performance, such as past
experience, role relationships, and cultural perspectives, that data from this study

revealed as signiﬁcant to professionals transitioning to a new role.

Copyright by
NANCY LEE SCHMITI'

2003

In loving memory of

Phyllis L. Kunath

ACKNOWLEDGEMENTS

I wish to acknowledge and thank those individuals who have been
inﬂuential and supportive in my work here. First and foremost I acknowledge and
extend loving gratitude to my family. Thanks to my husband, Bob Schmitt, for his
wisdom in providing active encouragement or silent support as my needs
dictated. Thanks to my sister, Janet Stolarski, who not only transcribed all of my
taped interviews, but also became an informed sounding board for my ideas.
Thanks to my sons, Jamie and Jake, and daughters-in-law Melanie and Nicky for
their votes of conﬁdence. Thanks to my grandson, Logan, for enticing me to play
and for helping me put my life's challenges in their proper perspectives.

I'd like to thank my committee members, John Dirkx, Kevin Ford, and
Steve VVleland for gently prodding me beyond my comfort zone, expanding my
perspectives, and stimulating my thought process. Thanks especially to Ann
Austin, my program advisor and committee chair, for taking me on and guiding
me through this arduous journey with the utmost of caring, consideration, and
professionalism.

Some very special friends also signiﬁcantly contributed to the momentum
and morale I needed to see this through. Thanks to my writing group, the
"Dissertation Divas." Fellow doctoral candidates, Patti Kenny, Pam Eddy and
Andrea Beach were each available to lend an eye, an ear, or an example on a
regular basis. Cathy Fleck, from the Writing Center on campus, kept us on

course (most of the timel). Andrea Beach deserves special recognition and

vi

gratitude for being my "bridge over troubled water." Her accessibility and
friendship in this process truly "eased my mind."

I'd also like to thank my employer Allmerica Financial and, in particular,
Assistant Vice President, Linda Ostach for generously supporting me with tuition
assistance and a ﬂexible work schedule that made the completion of this journey
possible. And last but not least, thanks to the nurses who participated in this
study. Their willingness to share their time and their stories was obviously crucial
to my project. Our visits proved to be insightful and enriching experiences that

has set the stage for further work on this subject.

vii

TABLE OF CONTENTS

TABLE OF FIGURES ............................................................................................ x
CHAPTER ONE- Problem Statement ................................................................... 1
Introduction ........................................................................................................ 1
Research Questions .......................................................................................... 5
Theoretical Constructs ....................................................................................... 5
Overview of Sample & Methods ......................................................................... 6
Researcher Perspective and Assumptions ........................................................ 7
Value of the Study .............................................................................................. 9
CHAPTER TWO - Literature Review .................................................................. 11
Introduction ...................................................................................................... 1 1
Nurses as Caregivers ...................................................................................... 13
Nurses as Case Managers .............................................................................. 16
Comparing Roles ............................................................................................. 24
Role Transition ................................................................................................. 25
Situated Cognition ............................................................................................ 32
Experiential Learning ....................................................................................... 34
Summary ......................................................................................................... 36
CHAPTER THREE - Research Methods ............................................................ 39
Introduction ...................................................................................................... 39
Participant Recruitment .................................................................................... 40
Sample Selection ............................................................................................. 4 1
Sample Description .......................................................................................... 43
Data Collection ................................................................................................. 46
Data Analysis ................................................................................................... 50
Delimitations and Limitations of the Study ....................................................... 52
Summary ......................................................................................................... 53
CHAPTER FOUR - Findings .............................................................................. 54
Introduction to Participants .............................................................................. 55

viii

Participants Who Practice Telephonic Case Management For A Worker’s

Compensation Carrier. ..................................................................................... 55
Participants Who Practice On-Site Case Management For Worirers’
Compensation Carriers .................................................................................... 60
Participants Who Practice Telephonic Case Management For A Health
Maintenance Organization ............................................................................... 64
Characteristics of the Transition from Care Giver to Case Manager ................ 67
Contextual Elements that Inﬂuence Nurses’ Experience of Transition ........... 113
Summary ....................................................................................................... 124
CHAPTER FIVE - Discussion ........................................................................... 127
Introduction .................................................................................................... 127
Revisiting the Conceptual Scheme Used in this Study .................................. 1 28
Themes Emerging from Data ......................................................................... 131
Recommendations for Preparing and Supporting Nurses in Transition. ........ 140
Implications for Professional Development .................................................... 142
Suggestions for Future Research .................................................................. 145
Conclusion ..................................................................................................... 146
APENDICES ..................................................................................................... 147
APPENDIX ONE ............................................................................................... 148
Interview Protocol .......................................................................................... 148
APPENDIX TWO .............................................................................................. 151
Participant Consent Form .............................................................................. 1 51
APPENDIX THREE ........................................................................................... 153
Participant Proﬁles ......................................................................................... 153
BIBLIOGRAPHY ............................................................................................... 191

TABLE OF FIGURES

Table 1. Comparison of Caregiver and Case Manager Responsibilities .......... 21
Table 2. Sample Summary .................................................................... 44
Table 3. Sample Demographics ............................................................. 56
Figure 1. A Model of Role Transition Process ............................................ 27
Figure 2. Elements of Practice Context that Inﬂuence Learning ..................... 34
Figure 3. Kolb's Model of Experiential Leaming ......................................... 35
Figure 4. Conceptual Scheme of Study ........................................... 37 & 128

Figure 5. Tensions Described by Nurses in Roles Transitions from
Caregiver to Case Manager .................................................................. 140

CHAPTER ONE - Problem Statement

Introduction

Novice to expert transitions within speciﬁc practice contexts have been
explored and described in adult education literature (Benner, 1984; Daley, 1999;
Drefus & Dreyfus, 1985; Houle, 1980; Knox, 1992; Mott, 2000; Raelin, 1997;
Scribner, 1984; Tennant & Pogson, 1995). Studies and theories addressing this
type of transition have provided educators and trainers with conceptual
frameworks for assessing performance and designing instructional programs for
adult learners at various levels of expertise. Relative little attention has been
paid, however, to expert to novice transitions that occur when professionals with
considerable experience and skill in one ﬁeld of practice take on new roles in
alternative practice contexts. An increasing trend in the number of occupational
changes made by professionals in the course of their careers (Ashforth, 2001;
Conger, 1997; Drucker 1994) makes this type of transition ripe for investigation.
As organizations respond to societal changes and economic constraints,
professionals are ﬁnding that traditional employment options are giving way to
varied and dynamic roles that often require competencies not achieved through
their foundational preparation or practice experiences. Advances in knowledge
and technology, changes in consumer awareness and expectations, and
resource and market ﬂuctuations precipitate new perspectives, priorities, and
problems to be dealt with in professional practice. Those with interests in

professional development need to attend to the particular training and

socialization needs of this growing segment of the workforce (Daley, 2001; Eraut,
1994; Ford & Fischer, 1997; Ibarra, 1999).

Whether professionals assume alternative roles voluntarily or by default,
the experience of transition and learning can impact job satisfaction and
ultimately the speed and ease with which optimal productivity is achieved
(Ashforth, 2000; Ibarra, 1999). In order to successfully recruit, retrain, or redirect
this talent pool, employers, educators and professional organizations will need to
be aware of the nature of expert to novice transitions, and assist professionals to
anticipate and deal with the required practice adaptations and gaps in knowledge
and skill that quickly need to be ﬁlled.

How professional nurses experience this type of career move and learn to
function in roles other than caregiver provides a good example of expert to
novice transitions. While foundational education and training provide nurses with
a knowledge base and procedural skills to care for patients, they do not
necessarily prepare nurses for roles that are emerging in the managed care
arena (“Adequate Training for New Hires,” 2001). Nurses are ﬁlling a growing
demand by healthcare provider systems and insurance companies for case
managers who oversee and coordinate utilization of services ('What's in the
Future? More Opportunities, Fewer Case Managers," 2003; Chan, Leahy,
McMahon, Mirch & Devinney, 1999). The healthcare and insurance industries
are looking to case managers for assistance in containing healthcare costs and
improving healthcare outcomes. Fulﬁlling responsibilities of this role not only

requires a familiarity with clinical aspects of healthcare, but also a knowledge

base and skill set for dealing with broader healthcare issues such as service
access and utilization, insurance regulations and policy provisions, and cost-
containment and quality outcomes. (Chan, et al., 1999; Conti, 1999; Falter,
Cesta, Conert & Mason, 1999).

Case management (CM) has emerged over the past twenty years as an
area of practice that appears well suited to the nursing profession. The growing
number of such positions being ﬁlled by nurses provides evidence for this. A
recent survey of practicing case managers demonstrated that 60% are registered
nurses (American Health Consultants, 2001). Education and training agendas,
however, are only beginning to address requisite knowledge and skills for case
management in undergraduate and advanced practice nursing curricula and
nursing literature (Conti, 1999), and information about the experience of
transition for professional nurses entering this ﬁeld is sparse.

Practicing nurse case mangers have achieved their role understanding
and competence primarily through self-directed learning and on-the-job
experience (Chan, et. al, 1999; Conti, 1999). This assertion is consistent with my
experiences and observations in coaching and supervising nurse case
managers. My experience working with nurse case managers, along with my
interest in workplace learning and professional development, has fueled a desire
to know more comprehensively how these professionals experience this role
transition.

This study focuses on the transition and learning experiences of

professional nurses in a career change from the role of caregiver to the role of

case manager. In care giving, nursing practice is focused on the patient. Nurses
as caregivers provide “hands-on” services such as administering therapeutic
agents and procedures, providing comfort measures, monitoring patients’
conditions and responses to treatment, and educating and supporting patients in
illness, recovery and wellness (Benner, 1984). In CM, the focal point of nursing
practice expands to include a number of stakeholders in the recovery or health
maintenance process (Meany, 1999; Mullahy 1998; Newell, 1996). Instead of
delivering hands-on care, however, case managers provide service though
collaboration with patients, healthcare providers and vendors, and third party
payers. This collaboration facilitates coordination of healthcare needs with
appropriate healthcare services and available payment resources across a
continuum of care (Chan, et. al, 1999; Conti, 1996; Falter, et. al, 1999; Meany,
1999)

Clinical nursing preparation and experience are assumed to provide a
good background for case management (Flarey & Blancett,1996; Mullahy, 1998;
Newell, 1996) which explains why nurses are sought after to ﬁll a growing
number of CM positions. Conti (1996) points out, however, that nurses
functioning in the role of case manager identiﬁed behaviors, (including
expediting, negotiating, brokering and researching) essential to case
management that received little or no attention in the nurses’ foundational
education and clinical practice. This illustrates a clear example of an expert to
novice transition and provides fertile ground for exploring the nature of such an

experience.

Research Questions
The main research question in this study is: How do nurses, primarily
trained and experienced as caregivers, transition to and learn in the role of
medical case manager?” Sub-questions include:

1. Are there characteristic motivations, expectations, sources of role strain
and job satisfaction, and learning experiences associated with the
process of this role transition?

2. What elements of contexts associated with past and present roles are
inﬂuential in this transition?

I developed a semi-structured interview protocol that provided a general aim for
the direction of my inquiry yet allowed respondents to explore their experiences

and reﬂections about transition fully and richly.

Theoretical Constructs

Three principal theoretical constructs are utilized in this study of the
process of role transition and learning. They are a Model of Role Transition
developed by Allen and van de Vliert (1984), situated cognition (Lave, Murtaugh
& de la Rocha, 1999; Wenger, 1998; Wilson, 1993), and a Model of Experiential
Learning developed by Kolb (1984). These theories form a conceptual scheme
that provides a basis for my inquiry into the experiences of transition for new
nurse case managers (NCMs).

The Model of Role Transition informed my questions about participants’

experiences of making a change from the role of caregiver to that of case

manager. This model provides a conceptual framework for understanding role
transition as a dynamic process of change and adaptation, impacted by
environmental as well as personal events and attributes. It informed my inquiry of
pre- and post- role change factors affecting participants’ acclimatization to the
role, as well as achievement of their present level of function and professional
identity as case managers.

The theory of situated cognition describes the role of context in learning
and comprehension. It contributed a focus to my inquiry on the contexts nurses
exit and enter during this transition, and the impact of elements associated with
those contexts on role learning and the development of expertise.

In order to more fully explore learning in the role of case manager, I used
a four-stage model of experiential learning (Kolb 1984). Kolb’s Model of
Experiential Learning is cyclical. It demonstrates a process that begins with
concrete experience and incorporates reﬂection on that experience, the formation
of abstract concepts and generalization that arise from reﬂection, and the active
experimentation that is used to test concepts and generalizations. This model
led me to inquire about speciﬁc experiences identiﬁed by participants as
signiﬁcant in shaping their current understanding of and ability to execute role

responsibilities.

Overview of Sample & Methods
I conducted semi-structured interviews with nurse case managers who

have had at least three years of clinical experience followed by not more than

three years experience in case management. I chose to limit participants to
three years of CM experience in order to harness relatively recent memories of
transition and learning experiences in the CM role. The interviews were recorded
on audiotapes and transcribed. In the tradition of grounded theory development
(Creswell, 1994; Merriam, 2001; Siedman, 1991), transcripts were analyzed for
emerging themes associated with the experience of transition and learning for
participants as they gained insights and skills as case managers. A more
thorough discussion of the methods and sample to be used in this study appears

in Chapter Three.

Researcher Perspective and Assumptions

I am currently employed by a ﬁnancial organization that holds property
and casualty insurance lines of business. This organization provides claim
services for individuals injured in work- and automobile-related accidents.
Nurses are employed here as case managers to assist with the claim process by
assessing healthcare needs related to the injury, and facilitating access to
appropriate healthcare goods and services. In this role, nurses collaborate with
the claimant (injured party), their employer, their healthcare provider, and the
claim adjuster. NCMs monitor the injured party’s understanding of the prescribed
treatment regime and progress toward recovery. NCMs also monitor claimants’
responses to prescribed treatment and discuss alternative treatment options with
providers if claimants are not progressing as expected. In workers’

compensation claims, NCMs work with employers to identify workplace or job

changes that accommodate temporary or permanent functional restrictions of the
injured parties.

My role in this organization is within the ranks of management. I provide
oversight for the case management program in terms of policy and procedural
compliance with a national nonproﬁt accrediting agency (URAC) and I am
responsible for recruiting, training and developing a qualiﬁed and competent
NCM staff for claims service. I have held a license to practice as a registered
nurse (RN) in the state of Michigan since 1972. l have been certiﬁed in case
management (CCM) from the Commission for Case Management Certiﬁcation
since 1991. l have a background of clinical experience in rehabilitation nursing
and also as a nurse consultant and case manager in the insurance industry. I am
a member of the Case Management Society of America.

Because of my nursing experience as a caregiver as well as a case
manager, there are certain assumptions l have about the transition from
caregiver to case manager, as well as the sample of volunteer participants. First,
I assume that foundational nursing education and training in providing care
contributes signiﬁcantly to the success of nurses performing the role of case
manager. That is, I believe that the stronger the clinical background in terms of
exposure to a variety of clinical settings, procedures, and interdisciplinary
approaches associated with illness/injury and recovery process, the more
resourceful a nurse will potentially be as a case manager. I assume that the
longer a nurse has spent in the clinical arena, the more apt he or she is to have

had a variety of clinical experiences that can contribute to greater ease in fulﬁlling

the responsibilities of a case manager. I assume that life experience or maturity
in general provides a signiﬁcant contribution to the success of making a role
transition of this type.

However, I believe that the transition from caregiver to case manager
involves more than applying clinical knowledge and acute care experience in a
different setting. I suspected that the transition and learning experience for
nurses as they make this practice-based career change presents some unique
challenges that have not been fully explored in the literature. My suspicion in this
regard has been raised by interacting with NCMs who have struggled in their
transitions and learning in terms of conﬁdence, professional identity, the scope
and boundaries of their CM practice, and legal and ethical accountabilities for CM
activities and inﬂuence.

With regard to volunteer participants, I expected most would be female, as
most nurses are female. Based on my experience in recruiting and interviewing
nurses for case management positions, I expected that most participants would

be over 35 years of age and have had over 10 years of clinical experience.

Value of the Study
The value of this study is two-fold. In a broad sense, it provides data
about expert to novice transitions in one ﬁeld that may have implications for
education and training agendas in other ﬁelds where similar types of role
transitions are taking place. Nurses and other professionals are faced with

evolving practice demands and opportunities in traditional as well as non-

traditional work environments. These changes present the need for effective role
transition and learning strategies that enable them to accommodate to new
performance expectations and to realize job satisfaction.

In a more speciﬁc sense, this study provides data about particular issues
faced by nurses in transition from caregiver to case manager. The demand for
experienced nurses to function as case managers is growing in the wake of a
serious nursing shortage. ('What's in the Future? More Opportunities, Fewer
Case Managers," 2003; Chan, et al., 1999; Falter, et al.,1999; Feuer, 2002;
Howe, 1999). mm experienced nurses at a premium, recruitment and retention
are foremost concerns for healthcare providers and insurance plans that seek to
leverage nurses' familiarity with healthcare systems and processes to control
costs and enhance the efﬁcacy of healthcare services.

As the demand for case managers grows, so too does the demand for
education and training programs that address speciﬁc role requirements and
adaptations that professional nurses face in this transition. This study enhances
our understanding of the process of role transition and learning for nurses who
make this practice-based career change, and contributes to our understanding of

what is signiﬁcant about professionals’ experiences of transitions to new roles.

10

CHAPTER TWO - Literature Review

Introduction

Case management (CM) is an area of practice engaged in by nurses and
other healthcare professionals to control healthcare costs though facilitating
timely and appropriate use of healthcare resources by patients, providers and
payers. Over the past twenty years, employment opportunities for nurses in this
area have expanded and continue to grow (Falter, et al. 1999; Howe, 1999).
Consequently, many nurses are taking advantage of this career alternative and
are making the transition from caregiver to case manager.

As the demand for case managers expands, so too does the need to
develop the means to educate and train competent practitioners. In a survey
exploring nurse case managers’ (NCMs) role behaviors and education (Conti,
1996), 70% of respondents reported that they gained necessary knowledge and
skill to perform case management largely on the job and through life experience.
In a review of nursing and CM literature from the previous ten years, Falter et al.
(1999) found that case management education is diverse and includes not only
continuing education courses and on-the-job training, but also some formal
undergraduate and graduate course content. The extent to which each of these
venues are available, utilized, or effective in preparing nurses for case
management responsibilities was not addressed, however. Another study of
educational approaches and issues in preparing nurses for case management

(Haw, 1996) indicated that while most faculty in academic nursing programs

11

studied had educational preparation in case management, many lacked
experience in the role. This suggests that research on practicing NCMs about
transition to and learning that occurs in the role would be a useful contribution to
faculty awareness and understanding of issues in CM ﬁeld experience.

In this study, I examined the processes of learning and transition for
experienced nurses who have made a career move from providing hands on care
to providing case management services. The focus of this study centers on
those experiences and insights that have been signiﬁcant in the transition to and
learning in the role of case manager for nurses whose foundational education
and professional nursing experience is in providing direct patient care.
Accordingly, the bodies of literature informing my inquiry include nursing, case
management, role transition, situated cognition and experiential learning.

In this review of literature, I will ﬁrst discuss the roles of caregiver and
case manager in order to provide a perspective of how these roles, though
sharing some foundational knowledge domains, differ in practice in a signiﬁcant
way. This information demonstrates the shift in focus and practice behaviors that
needs to occur when nurses move from one role to another. I will then discuss
literature on role theory and a model of role transition that helps in examination of
this process. I will discuss situated cognition and how contextual factors come to
bear on learning and performance. Finally, I will present a model of experiential
learning that contributed to a conceptual scheme for my interview protocol and

analysis of interview data.

12

Nurses as Caregivers

In order to approach nurses about their experience in making the
transition from caregiver (the traditional role of a nurse) to case manager (a
relatively new career alternative for nurses), it is essential to explore and
understand speciﬁc aspects of each role. In this section I will present a
comprehensive survey of behaviors that are characteristically associated with
nurses in the role of caregiver.

Benner (1984) identiﬁed seven domains of nursing practice. They are: (a)
the helping role, (b) the teaching-coaching function, (0) the diagnostic and patient
monitoring function, 4) effective management of rapidly changing situations (d)
administering and monitoring therapeutic interventions and regimes, (e)
monitoring and ensuring quality of health care practices, and (f)) organizational
and work role competencies. These domains encompass aspects of work for
which nurses are prepared through their professional education programs. Each
domain can be viewed as a category of either a hands-on or a facilitating
approach. For the purpose of this study, nurses described as caregivers are
those that provide a hands-on approach in their practice. Case managers by
distinction provide a facilitative approach. Table 1 provides a comparative survey
of each approach.

A basic premise of nursing care is the prevention of noxious inﬂuences
and the provision of life sustaining resources (Newell, 1996). As caregivers in
the helping role, nurses provide comfort measures and support in coping for

patients. Comfort measures include assistance with activities of daily living such

13

as hygiene, grooming, exercise and positioning. Coping support encompasses
creating a climate for healing through control of environmental variables.
Caregivers intervene in patients’ environments by identifying and removing
hazards, taking precautions, and introducing resources that are not only
conducive to healing, but stimulate or enhance patients’ growth and
development. Nursing interventions in this regard encompass the physical as
well as psychosocial environment.

Caregivers enact a teaching-coaching function that includes such activities
as probing to ﬁnd out patients’ interpretation of their illness and their readiness to
learn self care activities. “Hands on” teaching and coaching includes providing
patient education and counseling on health conditions, giving rationale for
procedures and explaining the implications of illness and recovery for patients’
lifestyles.

The diagnostic and monitoring function engaged in by caregivers includes
detection and documentation of signiﬁcant changes in patents’ conditions
through direct observations, physical examinations, and attention to patients’
concerns about and experience of symptoms. Caregivers record and report
patients’ responses to various treatment strategies in terms of vital signs such as
body temperature, blood pressure, heart rate, and respiration. Monitoring
activities include measuring ﬂuid intake and output, assessing changes in skin
conditions such as color, texture and integrity, and noting changes in strength

and joint mobility, as well as discrepancies in alertness or emotional reactions.

14

In providing effective management of rapidly changing situations, nurses
as caregivers recognize emergent physical conditions and respond immediately
In an effort to halt or reduce life threatening processes and restore life sustaining
processes until physician assistance is available. This requires an immediate
grasp of arising problems and the ability to match medical demands with
available resources. Skills in cardio-pulmonary resuscitation, and deﬁbrillation,
as well as knowledge of the administration of appropriate agents and procedures
are essential in this role.

Nurses as caregivers directly administer and monitor therapeutic
interventions and regimes. This includes dispensing medication, ﬂuids, and
nutrition though various means, performing procedures such as wound dressing,
bladder catheterization, and tracheal suctioning, facilitating appropriate amounts
of rest and exercise, and documenting patients’ conditions and responses.
Caregivers must therefore be current in knowledge and skill pertaining to
advances in pharmacology, medical technology, and various treatment protocols.

Caregivers to varying degrees monitor and ensure the quality of
healthcare practices. In this domain of nursing practice, caregivers assess the
safety or merit of prescribed treatment in light of the patient’s condition or
response. This entails determining what can be safely omitted or added to the
prescribed regime, and getting appropriate and timely responses from
physicians.

The practice domain of organizational and work-role competencies

encompasses the management and administrative responsibilities associated

15

with providing direct care. Behaviors of caregivers in this domain include setting
priorities among multiple demands on time and attention as they pertain to
meeting the immediate healthcare needs of assigned patients. Characteristic
behaviors may include building and maintaining working relationships with an
interdisciplinary team of health professionals that all contribute to the well being
of those patients, and whose services require coordination. This domain could
also include contingency planning when resources, such as staff, equipment, or

supplies, are limited.

Nurses as Case Managers

In this section I will provide background information about case
management as an area of practice and about content knowledge that has been
identiﬁed as foundational for CM. I will then differentiate the practice of case
managers from the practice of caregivers using Benner’s domains of nursing
practice (1984) as an organizing framework.

Evolving from social work and public health models, CM is viewed as an
effective strategy for containing healthcare costs and expenditures from both the
provider and the payer sides of the healthcare equation. From the patient
perspective, case management provides decreased fragmentation of care as well
as advocacy (Flarey & Blancett, 1996; Mullahy 1998; Newell, 1996). Through the
identiﬁcation of individuals or populations that present high ﬁnancial exposure, in
terms of actual or potential healthcare needs, and the coordination of timely

access and appropriate utilization of healthcare resources in order to meet those

16

needs, case managers have established their value in the world of managed care
(Falter et al., 1999; Howe, 1998; Lamb & Stemple,1994). .The Commission for
Case Management Certiﬁcation, (CCMC) deﬁnes CM as ”a collaborative
process which assesses, plans, implements, coordinates, monitors and
evaluates options and services to meet an individual's healthcare needs through
communication and available resources to promote quality cost effective
outcomes” (Mullahy, 1998 p.9).

CM is a multidisciplinary area of practice with representation from the
ﬁelds of nursing, social work, rehabilitation counseling, and occupational and
physical therapy (Mullahy, 1998). A recent survey of working case managers,
however, revealed that roughly 63% of respondents had a nursing background
(American Health Consultants, 2000). Nurses with strong clinical backgrounds
are sought after to practice in this area because of their presumed knowledge of
the healthcare system and understanding of care requirements associated
disease and disability.

Nursing and CM Iiteratures demonstrate numerous practice models and
settings for case management (Chan et al., 1999; Conti,1996; Falter et al 1999;
Howe, 1999; Lamb & Stemple, 1994; Mullahy, 1998; Newell, 1996; Nolan,
Harris, Kuffa, Opfer & Turner, 1998). Nurse case managers are employed by
hospitals and rehabilitation and extended care facilities to provide coordination
and oversight of the needed in-patient services and to monitor patient responses
to treatment protocols from admission through discharge. .NCMs are employed

in ambulatory clinics and health maintenance organizations (HMOs) to

17

coordinate on-going primary care of patient populations with at-risk and chronic
conditions such as high-risk pregnancies, cardiac disease, diabetes, and asthma.

Third party payers (i.e., organizations that provide health care insurance,
disability and workers' compensation insurance, and automobile personal injury
protection insurance) employ NCMs to identify health care needs associated with
illness or injury claims, to coordinate access to appropriate, cost effective
resources, and to monitor the recovery process through full recovery or
maximum medical improvement. Proprietary case management companies, or
CM vendors, who enter into service agreements with insurance companies,
attorneys or private individuals to perform case management services, also
employ NCMs.

Descriptive terminology associated with models of CM is found throughout
the literature. For example, case managers that provide CM services as agents
of healthcare provider organizations are commonly referred to as ”internal case
managers." Those who provide services as agents of third party payers are
commonly referred to as ”extemal case managers.” Case managers who
practice in the ﬁeld, making personal visits to patients’ homes or provider settings
to accomplish their tasks, practice what is referred to as "on-site CM.” Case
managers who accomplish their tasks exclusively by telephone practice
"telephonic CM.” Some case managers are ”independent." They are self-
employed and can enter into contractual arrangement for their services with

providers, payers, or private individuals.

18

Five core areas of knowledge have been identiﬁed as foundational to all
models of case management and are utilized by the CCMC for composition of
the case management certiﬁcation exam. These core areas of knowledge were
determined as a result of a national survey of 14,000 certiﬁed case managers
(Leahy, 1994). .They are (a) coordination and healthcare delivery systems, (b)
physical and psychosocial factors, (c) beneﬁt systems and cost beneﬁt analysis,
(d) case management concepts, and (e) community resources.

The core knowledge area of coordination and healthcare service delivery
includes knowledge of the injury or disease and recovery processes, available
treatment options, and strategies to access essential and cost effective
healthcare services and goods. Knowledge of physical and psychosocial factors
includes a comprehensive understanding of the interrelationship between
inﬂuences on states of illness and wellness such as physical condition and
functional abilities, psychological state and coping skills, cognitive capacity,
family relationships, and community support. .The beneﬁt systems and cost
beneﬁt analysis area of knowledge relates to familiarity with insurance coverage
contracts and beneﬁt provisions as well as cost containment strategies that do
not compromise the quality of prescribed healthcare services or goods.

Core knowledge of case management concepts refers to basic knowledge
and skills necessary to carry out the case management process including
assessment, planning , implementing, coordinating, monitoring, and evaluating.
The core knowledge area of community resources includes disability-related

legislation with regard to employment, accessibility in housing and transportation,

19

medical care, and other services available speciﬁcally for persons with chronic
illness and disabilities.

Case management has been identiﬁed as an area of practice for nurses
that utilizes elements of nursing theory (Newell, 1996) and capitalizes on nurses’
skills in assessment, outcome oriented interventions, monitoring responses and
communication in situations related to healthcare. The role of case manager,
however, requires some signiﬁcant change in the focus and selection of
behaviors within Benner’s domains of nursing practice as demonstrated in the
examples presented in Table 1.

In the helping role NCMs facilitate patients’ comfort and coping by
navigating the healthcare and beneﬁt systems that provide them with essential
services and ﬁnancial support. The teaching and coaching function is enacted by
NCMs as they identify healthcare service options and resources that patients can
choose from and assist patients with making their needs known to those who
provide care and ﬁnancial support. NCMs fulﬁll a diagnostic and monitoring
function by assessing patients’ healthcare needs, facilitating access to the
appropriate providers, and monitoring patients” overall progress in the recovery
process.

Although job responsibilities do not require NCMs to manage medical
emergencies, changes in health conditions, changes in beneﬁt coverage, even
changes in family relationships can present NCMs with the challenge of effective
management of rapidly changing situations through communication and

coordination of alternative services or coverage options. NCMs do not

20

Table 1. Comparison of Caregiver and Case Manager Responsibilities

 

Domains of Nursing
Practice
(Benner, 1984)

Examples of Caregiver
Responsibilities

Helping Role Assistance with hygiene, grooming,
positioning and ambulation.
Creating and maintaining an
environment free from harm and
conducive to healing and well
being.
Teaching & Patient and family education and
Coaching Function counseling about health
conditions and coaching in self-
and supportive care practices.
Diagnostic and Detection and reporting of
Monitoring Funcﬁon signiﬁcant changes in patients’
physical, emotional, cognitive
state through physical
examination and monitoring
laboratory reports.
Effective Life saving responses to physical
Management of and psychological emergencies.
Rapidly Changing
Situations
Administering and Directly dispensing medication,
Monitoring ﬂuids, and nutrition. Performing
Therapeutic procedures related to
Interventions respiration, elimination, mobility,
etc.
Monitoring and Assessment of safety and quality of
Ensuring Quality of prescribed treatment in light of

Healthcare Practices patients’ condition and

responses.

Organizational and
Work Competencies

Setting priorities to meet demands
on time and attention from
multiple patients.

Working with interdisciplinary
teams.

Contingency planning for scarce
resources needed for the
delivery of care.

21

Examples of Case Manager
Responsibilities

Facilitating access to healthcare
resources and available beneﬁts.

Creating an environment of open
communication and understanding
between patient, provider, payer and
other stakeholders in the community.

Patient education about health
conditions, care options and beneﬁt
coverage.

Provider education about beneﬁt system
and available ﬁnancial support.

Payer education about patients needs
and the cost of necessary care.

Community education about patients re-
entry needs.

Detection of changes in patients
healthcare needs based on patient,
family and provider feedback.

Detection of problems with insurance
coverage based on payer, provider
and patient feedback.

Responses to situations that threaten
continuity of needed care, beneﬁt
coverage, or patient adherence to
prescribed treatment.

Facilitation, coordination, and monitoring
needed therapeutic interventions.

Assessment of safety and quality of
prescribed treatment in light of
established treatment protocols and
patients’ ability and willingness to
participate.

Recognition and understanding the needs
and interests of multiple stakeholders.

Negotiating for the most cost effective
healthcare outcomes.

Acting as a liaison for effective
communication between patients,
providers and payers.

administer therapeutic interventions and regimes, rather they indirectly monitor
such interventions and regimes. Knowledge of evidence-based treatment
protocols and the review of medical records and progress notes put NCMs in a
good position to provide input to patients, providers and payers about the
appropriate use of therapeutic interventions and regimes.

Perhaps one of the most salient of all the domains of nursing practice for
NCMs is the function of monitoring and ensuring the quality of healthcare
practices. NCMs’ activities in this domain include assessing the merit or safety of
prescribed treatment in light of the patients’ willingness and ability to comply with
plans of care, their concurrent healthcare or psychosocial needs, and the
availability of healthcare beneﬁts for ﬁnancial assistance.

The practice domain of organizational and work-role competencies for
NCMs encompasses a knowledge base of the multiple stakeholders involved,
and skill in balancing priorities of patients, providers, and payers in order to
render the best healthcare outcome at the most reasonable cost. This entails
behaviors such as relationship building, negotiating, coordinating, brokering, and
researching.

Conti (1996), by way of a survey study, identiﬁed 16 behaviors
characteristically engaged in by nurses performing in the role of case manger.
These behaviors in order of frequency include monitoring, problem solving,
expediting, public relating, communicating, educating, contacting, planning,
explaining, recommending, coordinating, documenting, assessing, negotiating,

educating, brokering, and researching. She also found the majority of nurses in

22

her study indicated that the source of learning for this role, with all identiﬁed
attendant behaviors, was employment and life experience. Conti contends that
the majority of these behaviors have received little or no mention in the nursing
literature and recommends that the scope of practice of nurse case managers be
subjected to substantive examination and discussion.

It is within the past twenty years, and most recently with the proliferation of
a "managed care” environment, however, that additional models and CM have
developed to suit a variety of practice settings - all with an eye on containing
healthcare costs. As such, NCMs have had to deal with competing interests
related to cost containment, obligations to employers, and patient advocacy.
Mullahy (1999) addresses several ethical issues routinely faced by case
managers. They include patient versus payer rights, patient noncompliance,
efﬁcacy of treatment, employer involvement, cultural diversity, and under-
utilization of services. Litigation, insurance fraud, guardianship, conservatorship,
informed consent, conﬁdentiality and other medical-legal issues also pose
dilemmas for case managers in the course of practice (Banja, 1998, 1999).

Nurses practicing as caregivers may encounter a number of these issues
in providing direct care to patients, however the number of stakeholders to be
considered in healthcare scenarios expands for case managers. As a
collaborative process, CM necessarily acknowledges and attends to interests of
both the individual in need of healthcare and the systems within which healthcare

is accessed, provided, and supported (Meany, 1999).

23

Comparing Roles

Though it appears that Benner’s domains of nursing practice (1984)
incorporate some of the behaviors identiﬁed by Conti (1996) as integral to the
case manager role, some signiﬁcant qualitative differences are apparent.
Speciﬁcally noteworthy are (a) time perspectives (more immediate for the role of
caregiver; more extended timeframe for case management activities), (b) the
mode of provision of healthcare goods and services (provided directly by a
caregiver; coordinated and facilitated by the case manager), and (c) setting
(healthcare provider organization for the caregiver; healthcare provider or payer
organization for the case manager). Also though initial formal preparation in
nursing, as well as clinical experience in the caregiver role, may provide some
foundational knowledge and skill on which to build expertise in case
management, according to respondents in Conti’s study (1996) there are on-the-
job and general life experiences that have helped case managers become
functional in their practice.

An appreciation of the foundational knowledge and scope of practice
expectations of both the caregiver and case manager roles informed my line of
inquiry into the signiﬁcance of acquired clinical knowledge and experience in
transitioning from caregiver to case manager. Exploring how care giving
experiences may have or have not contributed to participants’ effective case
management practices, and the instructive value of speciﬁc CM experiences on-

the-job provided insight into successful role transition and learning strategies.

24

Role Transition

Role theory provides a useful conceptual framework for exploration of
changes in work practices, relationships and identities. Murray (1997; 1998)
used role theory to examine nurses’ transitions from hospital-based nursing
practice to home care nursing. She relates that although a signiﬁcant amount of
nursing literature exists that addresses the transitional experience and needs of
nurses new to the practice setting, literature that addresses the transitional
experience and needs of nurses who move from one area of practice to another
in the course of their professional career is scarce. She further contends that
educators can impact the degree of role strain experienced, and ultimately the
success of role transition of nurses making practice-based career changes by
incorporating role theory concepts into orientation and continuing education
programs. In this section, I will discuss a model of the role transition process that
utilizes role theory concepts and language. I will ﬁrst present a brief overview of
the basic assumptions of role theory. I will then explore Allen’s and van de
Vliert’s Model of the Role Transition Process (1982) in depth, and describe how it
contributes to the conceptual framework of this study.

Biddel (1979) deﬁnes role theory as “a science concerned with the study
of behaviors that are characteristic of persons within contexts and with various
processes that presumably produce, explain or are affected by those behaviors.”
He points out that role theory provides us with a means of studying both the
individual and the collective within one conceptual framework, because it is the

"theoretical point of articulation between psychology and sociology.” He offers

25

ﬁve basic propositions that underlie this science. They are: (a) Roles consist of
patterned behaviors that are characteristic of persons within contexts; (b) Roles
are associated with sets of persons who share a common identity; (c) To some
extent persons performing a role are governed by expectations that exist and are
shared about normative performance; (d) Roles persist because of their function
and perceived necessity in larger social systems; and (e) Roles are learned
through socialization and people may ﬁnd either joy or sorrow in performing
them.

Two basic approaches to role theory have been discussed in literature,
those being structuralist and social interactionist perspectives (Ashforth, 2001;
Ebaugh, 1988). A debate between these two perspectives is essentially whether
a person “takes” or “makes” a role. The structuralist approach views the role, or
expected behaviors to be an objective identity or utility that a person takes on by
fulﬁlling certain responsibilities or objectives. The social interactionist approach
views the role as an identity or utility that is ultimately negotiated between the
person engaging in expected behaviors and the context within which the role
resides. The social interactionist view allows that the person transitioning from
one role to another brings personal values, goals, meanings and attitudes from
previous roles that impact the way the new role is understood and enacted. This
study is aligned with this view.

The concepts and propositions of role theory are useful in studying role
transition because they offer a lens with which to view issues affecting persons

exiting and entering different contexts, trying on new identities, and performing

26

new behaviors. Through this lens we can identify social, environmental, and
individual aspects and processes that produce patterns of behavior, and how and
why expectations about these patterns are sustained or are changed.

Allen and van de Vliert (1982) developed a Model of the Role Transition
Process that incorporates the social interactionist perspective of concepts and
propositions of role theory. This model accommodates a dynamic interplay of
social positions, expectations and behaviors that move individuals toward
personal growth and adaptation in a role or toward role exit. Figure 1
demonstrates the sequential component parts of the role transition process,
which include antecedent conditions, role transition (behavior shift), moderators,

role strain, reactions, and consequences.

 

l I l l l

Role Reactions Consequences

Antecedent Role
Conditions + Transition T . Strain T. T.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Moderators

i

Figure 1. A Model of Role Transition (Allen & Van de Vliert, 1982)

 

 

 

 

Antecedent conditions are motivating factors that inﬂuence individuals to
move from one role to another. These motivating factors can operate on various

levels. On the level of the individual engaged in transition, for example,

27

antecedent conditions might be a change in capabilities, values, or ﬁnancial
needs. For nurses making a change from caregiver to case manager, a personal
motivation might be more desirable compensation or schedule ﬂexibility. On an
organizational level antecedent conditions might include a change in market
share, resource availability or mission that either attracts an individual to a new
role, or renders the existing role occupied obsolete or no longer acceptable to the
individual. Nurses working in clinical settings as caregivers may deal with
sustained staff shortages, or threatening hospital closings or mergers, by looking
for alternative career options.

The role transition process as a component part of the model (as opposed
to the model in its entirety) refers to the actual shift in behavior that occurs when
individuals exit one role and enter another. According to Allen and van de Vliert
(1984), there are three factors that inﬂuence this shift in terms of the permeability
of old behaviors into the new role. These factors are: (a) the degree of
discontinuity between old and new behaviors, or how different the expected
behaviors in the new role are from behaviors undertaken in the old role; (b) the
accuracy of the transitioning person’s anticipation of problems that will be
encountered in shifting behaviors; and (c) the extent to which role entry and the
assumption of new behaviors and responsibilities is formally structured and
governed, as in a formal orientation, apprenticeship or internship program.

Allen and van de Vliert (1982) and others (Ashforth 2001; Nicholson,
1984) point out that the degree of discontinuity in expected behaviors between

old and new roles can inﬂuence the degree to which old behaviors are carried

28

into the new role, and the degree to which new behaviors are accepted as more
desirable. There is obviously a signiﬁcant degree of discontinuity between
expected behaviors of caregivers and those of case managers in terms of the
provision of direct care versus the facilitation of appropriate cost effective care.

Hordijk, Muis and Van de Viler (in Allen & van de Vliert, 1982) found that
both overly optimistic and overly pessimistic anticipation of problems associated
with a new role caused more role strain than an appropriate anticipation of
problems. Nurses entering the role of case manager may be aware of overt
differences in expected behaviors, such as the shift from providing direct care to
facilitating appropriate, cost effective care. They may not, however, be aware of
the nature of the politics involved or ethical dilemmas that case managers face.

The remaining factor signiﬁcant to the transitional shift in behavior is the
extent to which the change is nonnatively governed; that is, the extent to which
the challenges of role learning and socialization in the transitional phase are
identiﬁed and planned for (Eraut, 1994). Exploring the experiences of NCMs with
regard to the nature and effectiveness of their initial orientation to CM and early
training agendas add to our understanding about the impact of contextual factors
on this role transition.

The component of role strain in Allen and van de Vliert’s model refers to
the subjective experience of the person in the process of transition. Feelings of
discomfort, disequilibrium, anxiety, and perplexity are often part of the transition
process (Ashforth, 2001; Biddel, 1979; Ebaugh, 1988). Factors affecting the

degree of role strain experienced by individuals may include the clarity of

29

expectations and boundaries associated with the new role and the meaning
ascribed to accomplishing the transition — as a loss or gain of function, status, or
esteem. Case management expectations and boundaries are not so clearly
deﬁned as clinical procedures.

Moderators are individual and environmental variables that can inﬂuence
the intensity of role strain and ultimately impact other components of the process.
On the level of the individual, for example, personality, locus of control, self-
conﬁdence, and social identity can modulate the transition experience to produce
more or less strain. Contextual or environmental factors such as social networks,
support for learning and the availability of resources can also work to exacerbate
or diminish the experience of role strain (Carkhuff, M, 1996; Daley, 2001).
Moderators in case management may include such things as the amount and
kind of clinical and life experience the transitioning nurse has to draw from, the
availability of a cohort within and outside of the employing organization, and
support from the organization in terms of time and reimbursement for
participation in professional organizations and continuing education programs.

Reactions refer to attempts by the individual to reduce role strain.
Reactions can be the activation of accommodations in self or the environment to
accomplish this. Seeking out more information and working to enhance or gain
speciﬁc skills are reactions to role strain. Seeking to change behavioral
expectations of the new role to comply more with existing skill levels and
interests is also a reaction. Exploring how nurses react to strain experienced as

beginning and novice NCMs and how effective or ineffective particular reactions

30

prove to be provide helpful insight for those interested in facilitating effective
transitions into this role for nurses.

Consequences are those intended or unintended outcomes resulting from
the focal person’s attempts to deal with role strain. These outcomes can be an
alteration in any of the other components of the process and be short or long
term. For example, a nurse making the transition from caregiver to case
manager may react to role strain by networking with other case managers to
learn more effective practice strategies. The introduction of successful new
practice strategies shifts behavior even more (role transition). Performance of
new behaviors can either serve to increase or decrease role strain and produce
new reactions. lf role strain is increased, a subsequent rejection of aspects of
the role that are intolerable may become new conditions antecedent to another
shift in roles (from case manager back to caregiver, for example). If strain is
decreased, the new skills acquired and success experienced may consequently
become a moderator, such as a change in professional identity that serves to
modulate role strain associated with any subsequent behavior changes.
Participant descriptions of consequences of their reactions complete a picture of
the process of role transition.

In summary, utilizing Allen’s and van de Vliert’s Model of the Role
Transition Process (1982) provides a conceptual frame within which to examine
several dimensions of the experience of change and learning for nurses moving
from the role of caregiver to that of case manager. Based on components of this

model, my inquiry encompassed individual, environmental and social conditions

31

that lead nurses to initiate this change in their careers, descriptions of speciﬁc
behavioral changes involved in assuming a CM role, the nature of discomfort or
difﬁculty associated with making these behavioral changes, and strategies

employed and outcomes experienced in dealing with role strain.

Situated Cognition

Research indicates that context, in terms of physical setting, tools, social
networks, cultural norms, and personal meaning, is inextricably linked to learning
and performance (Daley, 1997; Eraut,1994; Lave,Mutaugh, & de la Rocha, 1999;
Merriam & Brockett, 1997; Schon ,1983, Wenger, 1998; Wilson, 1993). Context
provides learners with a scope, an aim and a scale of priority for skills and
concepts to be learned, and/or tasks to be accomplished. Situated cognition
refers to a process of learning and comprehension that is tied to context (Brown,
Collins & Dugid, 1989, Wilson, 1993). According to this conceptual frame,
learning is a recursive process in which individuals gain knowledge and
competence in context through membership in social networks, utilizing tools,
and setting and solving problems that are particular to that context. The
implication of situated cognition in studying role transition and learning for nurses
moving from caregiver to case manager is the need for educators and trainers to
appreciate the impact of contextual factors on role learning and performance.

Lave et.al. (1999), for example, demonstrated the role of contextual
elements in problem solving in what has been referred to as “the supermarket

study.” In this study, adult subjects more aptly and accurately solved

32

mathematical problems in a context of grocery shopping as compared to the
outcome of their efforts in solving similar problems offered by way of a paper and
pencil test. Researchers noted that the context of grocery shopping offered
subjects speciﬁc tools and framed solution expectations that differed from the
context of traditional academic testing. Shon (1983, p.40) has argued as well
that “Problem setting is a process in which, interactively we name the things to
which we will attend and frame the context in which we will attend them.”

Fundamental nursing education and training is concerned with preparing
individuals to be competent caregivers. Foundational preparation in nursing has
historically been followed by clinical experience obtained in the context of an
acute care setting. In this context, the caregiver’s attention is directed quite often
at a single episode of illness and medical treatment in a setting that provides
distinct tools and expectations for practice. Nurses making a career change to
case management, however, move into a new context that holds new
expectations, new social structures, new tools, and potential new identities.
Inquiry aimed at discovering contextual elements that inﬂuence nurses’ transition
to and learning in the role of case manager was informed by a theory of situated
cognition. Figure 2 demonstrates elements of practice settings that inﬂuence
Ieaming, and accompanies the individual’s entry into subsequent practice
contexts.

Role identity is associated with context because it is developed through
interaction with contextual elements such as technical information, role

expectations, organizational structure, appraisal information, cultural norms and

33

political climate (Ashforth, 2001). The concept of role identity, or how individuals
deﬁne their rights and responsibilities in relationship to others, becomes an issue
in role transition and learning because of its inﬂuence on the knowledge and
skills selected for learning in the pursuit of competence. Wenger (1994, p. 215)

states, “We accumulate skills and information, not in abstract ends in

 
        
 
    
  
   
    

. Practice Context A Practice Context B

   
  
  
  
  
  
 

Practice setting

Job responsibilities 8-
pnonﬁes

Tools & learning resources

Social network ,

Professional identity

Personal motivations

  
   
  
  
  
  
  

Practice setting

Job responsibilities 8-
pnoﬁﬁes

Tools 8- learning resources

Social network

Professional Identity

Personal motivations

Figure 2. Elements of Practice Contexts that Impact Learning. It also represents how inﬂuences
from elements of past contexts are brought into and modiﬁed by subsequent practice contexts.

themselves, but in service of an identity.” For these reasons, it was important to
explore how NCMs view differences in relationships to clients, coworkers,

colleagues and others with whom they regularly interact from that of relationships

they participated in as caregivers.
Experiential Learning

Kolb offers a model that provides a plausible explanation of how learning

from experience occurs. It consists of a cycle of concrete experience, reﬂective

34

observation, abstract conceptualization, and active experimentation (Kolb, 1994).
Figure 3 demonstrates this model.

According to this model, the learner is ﬁrst engaged in some activity or

Concrete

/ Experience \

Active Reﬂective
Experimentation Observation

\ Abstract /

Conceptualization

Figure 3. Kolb’s Model of Experiential Learning (in Davis, 1993)

encounter. Following this the learner reﬂects upon the meaning of that
experience in terms of personal signiﬁcance, logic, and value, and then
formulates abstract conceptualizations about what has taken place. Testing of
the abstract conceptualizations ensues through a process of active
experimentation, which returns the learner once again to concrete experience. At
this juncture, the cycle repeats.

It is feasible that progressive expertise is accomplished with each
successive journey though this cycle (Benner, 1984; Dreyfus & Dreyfus, 1985). It
has been argued, however, that learning from experience without guidance is
subject to the learner’s interpretation of experience. Left to their own
interpretations, learners can conceptualize erroneous theories, which then

become self-conﬁnning in subsequent experiences (Eraut, 1994).

35

Conti(1996) indicated that 75 % of NCMs she surveyed reported that they
learned case management “on the job.” This suggests that experiential learning
is an appropriate theoretical frame with which to investigate how nurses learn to
function in the role of case manager. Guided by Kolb’s model, I formulated
interview questions to bring out recollections of speciﬁc experiences that
participants ﬁnd instrumental in learning to function as a case managers, and
opportunities they have to review or discuss cases and problem solving

strategies.

Summary

Case management is a growing ﬁeld of practice in systems of healthcare
delivery and insurance claim payment. Nurses are sought after to ﬁll case
management positions because of valued clinical knowledge acquired through
nursing education and experience as caregivers. Though foundational nursing
education and experience as caregivers provide nurses with valuable insight into
issues related to illness and recovery, this background does not necessarily
prepare them to assume a role that requires the development of new skills and
application of their knowledge base in a different context. This study identiﬁed
salient characteristics of the processes of role transition and learning that have
provided professional nurses with the knowledge and skills to function effectively
as case managers.

l assembled a conceptual scheme for studying the nature of role transition

and learning for nurses making a practice based career change from that of

36

caregiver to case manager. This scheme as illustrated in Figure 4 utilizes
theories of situated cognition, role transition and experiential learning.
The concept of situated cognition directed my attention to the impact of context

on Ieaming and comprehension in practice. Understanding the practice

 
     
 
      
  
 

Cate lelng

Context
Role
Transition

-
m

         

 

Antecedent
Conditions

   

 

 

 

'1"

Experiential
Learning

  

Figure 4. Conceptual Scheme of Study combines the inﬂuences of past and present role
contexts with Allen & van de Vliert's Model of Role Transition (1982), and Kolb's Model of
experiential Ieaming as a reaction to role strain.

contexts that nurses exit and enter in this transition is therefore signiﬁcant in
understanding their experiences of transition and learning. A Model of the Role
Transition Process (Allen & van de Vliert .1982) contributes a structured
approach to exploring a dynamic process of change and adaptation. This model
provided pathways and milestones for exploring nurse case managers'
reﬂections on experiences associated with role transition. This model includes

factors and motivations precipitating role transition as well as experiences of role

37

strain and the consequences of problem solving strategies to reduce it. Learning
in a new role, however requires an emphasis in this study not speciﬁcally
addressed in Allen's and van de Vliert’s model. Kolb’s Model of Experiential
Learning (1984) provides a format for that emphasis. Kolb’s model guides this
study toward identiﬁcation of concrete experiences in CM practice that lead to the
development of knowledge and expertise. It also leads me to explore the
opportunities afforded to nurse case mangers for formal and informal reﬂection,
conceptualization and testing of their conclusions about effective case

management.

38

CHAPTER THREE - Research Methods

Introduction

Case management is a career opportunity for nurses. Such opportunities
are increasing as the healthcare providers and payers seek ways to control costs
without sacriﬁcing the quality of care needed by consumers (Chan et al, 1999;
Conti, 1996; Falter et al, 1999; Howe, 1999). While current literature addresses
foundational knowledge and skills essential for effective case management, there
is a gap in information on how nurses learn to apply their foundational education
and experience as caregivers and acquire new competencies as case managers.
This qualitative study, demonstrating patterns of transition to and learning in the
role of case manger for nurses who have been primarily educated and
experienced as caregivers, begins to ﬁll that gap.

A qualitative study is appropriate for seeking out this kind of knowledge
because it allows for exploration and description of personal experience and
meaning in speciﬁc contexts (Creswell, 1994). The methods of inquiry and
analysis I used are based on the conceptual framework of symbolic interaction,
which holds that people create meaning from experiences through interactional
responses to situations (Bogdin & Biklin, 1998). These methods accommodate
in depth exploration of the interplay of personal meaning and situational factors
described in the theories that l have chosen to inform my inquiry and data
analysis. Theories of role transition, situated cognition and experiential learning

led me to explore phenomena comprised of the interplay between contexts,

39

motivations, tensions, accommodations and reﬂections. The investigation of this
interplay as it pertains to role transition and learning for NCMs, required detailed
descriptions of past experiences and present reﬂections not accessible through

quantitative methods of research.

Participant Recruitment

An explanation of this study along with a call for volunteer participants was
presented at two local meetings. One was a local chapter meeting of the Case
Management Society of America (CMSA) and the other was a local meeting of
the Rehabilitation Insurance Nurse Council (RINC), both in a Midwest
metropolitan area. CMSA and RINC are both professional organizations.
RINC’s membership consists only of NCMs who are speciﬁcally associated with
insurance carriers either by employment or by contract. CMSA’s membership
has representation from a variety of disciplines, that is case managers who are
nurses as well as others who are social workers, occupational therapists, or
physical therapists, and is also inclusive of case mangers associated with
healthcare providers as well as payers. These organizations routinely meet on a
monthly basis for the purposes of member networking and continuing education
on topics of interest to NCMs. Volunteers presented their interest in participating
directly to me or indirectly through other NCMs who had attended the meeting. I
also contacted supervisors at three CM vendors and requested referrals to any of
their staff that ﬁt the desired proﬁle. One supervisor referred me to two of her

staff.

40

I phoned potential subjects and briefed them on the nature of the study
and screened them for ﬁt with the desired sample proﬁle. A convenience sample
of eleven NCMs was selected from ﬁfteen volunteers to provide data for this

study.

Sample Selection

A purposeful sample with consideration to maximum variation in cases
was determined to be appropriate for this study. Purposeful sampling is based
on the assumption that a criterion-based sample selection serves the need for in-
depth study of information-rich cases. Criteria for sample selection reﬂect the
purpose of the study and guide identiﬁcation of information-rich cases. (Merriam,
2001; Seidman 1991). Maximum variation in cases selected contributes to the
identiﬁcation of the relative strength of shared patterns that emerge from data,
even in small samples (Merriam, 2001).

Participants selected were practicing NCMs who had at least three years
of hospital or clinic based experience beyond foundational nursing education and
training prior to taking on the role of case manager. Because CM is practiced in
various settings, an attempt was made to limit participants to those currently
practicing in payer environments (insurance companies that are involved in
paying health beneﬁts). They also were required to have practiced in the role of
case manager from one to three years. Age, gender, or ethnicity was not part of

the selection criteria.

41

While years of experience do not necessarily correspond to a predictable
level of role understanding or competency, Dreyfus and Dreyfus (1986)
demonstrated that professionals move through progressive stages of
competency toward expertise and that these stages roughly correlate to time on
task. Based on their study of individuals performing in a number of occupations
with varying amounts of experience, they developed a Model of Skill Acquisition
and labeled these stages as novice, advanced beginner, competent, efﬁcient,
and expert.

According to this model, a professional with up to one year of experience
generally functions as a novice. I have chosen to exclude novice NCMs from this
study because I do not believe that they would be able to provide the scope of
recollection and the degree of insight I am seeking. As Dreyfus & Dreyfus point
out, the novice has little to no experience to draw from in analyzing a situation
and choosing behaviors appropriate for goal accomplishment. Goals of behavior
for this stage are generally short sighted, if present at all. Objective features of
tasks are used to gain entry into a situation and consciously attend to “context
free” or “text book” rules to help make determinations of the “correct“ course of
action. Novice NCMs may be able to compare contexts and describe tensions
experienced in the transition at hand. I speculated, however, that role
understanding and Ieaming strategies may be limited at the novice stage to a
degree that is signiﬁcantly less informative than input from NCMs at the
advanced beginner stage (one - two years of experience) or the competent stage

(two - three years).

42

I chose to exclude NCMs with greater than three years of experience in
order to capture experiences of role transition and Ieaming with more accuracy.
According to Dreyfus & Dreyfus, as professionals’ progress through the proﬁcient
(three-ﬁve years) and expert (greater than 5 years) stages of skill acquisition,
they begin to rely more on intuition for problem solving. They develop the ability
to zero in on an accurate region of a problem and determine a viable solution
almost immediately, and often have difﬁculty describing this ﬂuid process. I was
concerned that NCMs with advanced experience levels may have also found it
difﬁcult to recall the impressions, tensions and strategies that were signiﬁcant in

their own processes of role transition and learning.

Sample Description

Table 2 presents the demographic data of the sample of participants for
this study. Participants were all female registered nurses (RNs), which is
consistent with the most represented gender in the nursing profession and also in
the ﬁeld of medical case management. Although male participants were not
excluded from the study by design, no speciﬁc attempt was made to insure
representation. Six participants were between 41 - 50 years old. Three
participants were over the age of 50. The only participant under the age of 40
was 29 years old.

Seven participants earned Bachelor of Science degrees in Nursing (BSN).
One of those also completed a Master of Arts (MA) degree in Healthcare

Administration and another is completing a Master’s degree in Exercise Science.

43

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Four participants earned Associate Degrees in Nursing (A.D.N.). One of those
is currently enrolled in a BSN program, and another is enrolled in an accelerated
Master of Science in Nursing (MSN) program.

Participants’ years of experience as caregivers in healthcare provider
settings ranged from 5 to 31 years. Five participants had more than 20 years of
experience as caregivers. Three participants had between 10 and 20 years of
those is currently enrolled in a BSN program, and another is enrolled in an
accelerated Master of Science in Nursing (MSN) program.

Participants’ years of experience as caregivers in healthcare provider
settings ranged from 5 to 31 years. Five participants had more than 20 years of
experience as caregivers. Three participants had between 10 and 20 years of
experience and three participants had less than 10 years of experience as
caregivers.

Clinical contexts where they performed in roles of caregivers were multiple
for many participants and included various hospital in-patient units, namely
medical surgical units (ﬁve participants); orthopedic units (two participants);
intensive and critical care units (two participants); pediatric unit (one participant);
and obstetric and gynecology units (one participant). Out-patient or ambulatory
clinic settings included emergency care (four participants); pediatric clinics (three
participants); public health clinics (two participants); general practice clinics (two
participants); and occupational health clinics (one participant). Four participants
gained care giving experience in the home care context, and one participant

provided care in a skilled nursing facility.

45

Participants’ work experience as NCMs ranged from one to three years.
The majority of participants (six) fell into the range of one to two years of CM
experience. Three participants have worked as NCMs for one year and three
have performed in the role for two to three years.

Two national workers’ compensation (WC) insurance carriers employ ﬁve
participants. Four of those are employed by one carrier and practice telephonic
CM. One participant is employed by the other WC carrier and practices on-site
CM. Three participants are employed by two CM vendors that provided
contractual CM services for WC, automobile, and disability insurance carriers.
These participants all practice on-site CM. Two of these participants work for the
one of the CM vendors. One participant works for the other vendor. The
remaining three participants are employed by two health maintenance
organizations (HMOs). Two participants work for one of the HMOs and one

particpant works for the other.

Data Collection
Data were collected through loosely structured individual and focus group
interviews with experienced nurse case managers. Interviewing is a method of
inquiry that allows participants to explore their own experience and assign a
personal meaning to that experience (Bogdan & Biklen, 1998; Cresswell, 1994;
Merriam, 2001; Seidman, 1991). Through dialogue on contextual variables, and

reﬂections on transition and Ieaming experiences, I gained insight into how these

46

professionals experienced role transition and learned how to function as case
managers.

Seidman (1991, p. 3) explains, “At the heart of interviewing research is an
interest in other individuals’ stories because they are of worth.” .NCMs’
perceptions of contextual inﬂuences and personal accounts of transition and
learning are of worth to me speciﬁcally because of my responsibilities involved
with training and development of nurses as case managers. . believe such
accounts and reﬂections are also of worth to the area of nursing and case
management because of the increasing opportunities for nurses to ﬁll this role,
and a need to develop education and training programs that comprehensively
address Ieaming needs in this area of practice. In addition, these accounts and
reﬂections contribute to out understanding of how professionals in general
approach and develop in new roles

Personal interviews began in the phenomenological tradition of the “grand
tour” questions. Grand tour questions are posed in a general way so as not to
limit respondents in their replies (Bogdan & Biklen, 1998; Cresswell, 1994;
Merriam, 2001; Seidman, 1991). vThis approach allowed NCMs to describe
personal experiences and observations of phenomena addressed in the
theoretical frames of situated cognition, role transition and experiential learning
that contribute to the overall conceptual scheme of this study. Taking cues from
responses to the grand tour questions I pursued more explicit descriptions of

practice contexts and reﬂections on experiences of transition to and Ieaming in

47

this role, as well as reﬂections on how these things have come to bear on their
current understanding and practice of case management.

Speciﬁc questions associated with situated cognition included: “Tell me
about the different contexts in which you have practiced as a professional nurse.”
“How would you describe the principal differences between the practice context
of a caregiver and that of a case manager (e.g. rights, responsibilities, resources,
support structure, etc)?” “How do the resources that were available to you for
learning to provide hands-on nursing care compare with the resources that are
available for you for learning to function as a case manager?

Questions associated speciﬁcally with role transition included: “Describe
what the transition from caregiver to case manager was like for you.” “What
motivated you to make this career change?” “Where does this role ﬁt in your
career plan?” “In what ways have your clinical knowledge and care giving '
experience prepared you to assume the role of case manager?” “Which
expectations and responsibilities of a case manager did you feel least prepared
to fulﬁll?” “Describe the sources of conﬂict or strain that you experience in
assuming and developing in the role of case manager.” “What environmental or
personal accommodations help you to feel more comfortable or conﬁdent in the
role?” “What do you ﬁnd satisfying or rewarding about case management?

Questions associated with experiential learning included: “How did you go
about Ieaming to practice case management?” “Which experiences do you recall
as signiﬁcant in your Ieaming the core knowledge areas of CM?” “ What have

you learned essentially through formal means (e.g. pre-service courses, in-

48

service or continuing education programs?“ “What opportunities do you have to
review or discuss cases for the purpose of increasing knowledge or improving
performance?” “Looking back over your experience of role transition from
caregiver to case manger, what was most helpful in terms of socialization and
learning?”

Personal interviews were recorded on audiotape and transcribed verbatim.
Once I reviewed transcripts and identiﬁed themes and nuances, I facilitated two
focus group discussions with volunteer participants. This provided additional
opportunities for participants to reﬂect on how their experiences were consistent
or inconsistent with themes presented as having emerged from individual
interview data. Having NCMs respond to themes emerging from individual
interviews with colleagues contributed to my insight into the similarities and
differences in the experience of role transition and learning inherent in this
practice-based career change. Benner and Wrubel (1982), for example, found
that experienced clinicians were able to discover signiﬁcant aspects of clinical
experiences through dialogue with peers.

The focus group method of data collection has found increased
acceptance and popularity in social science research. (Morrison & Peoples,
1999) This technique has been utilized to stimulate discussions in homogeneous
groups to help determine common and contrasting opinions, perceptions and
reﬂections on specific topics. Underlying assumptions about the validity of this
approach include: (a) a homogeneous group can create a milieu in which

participants experience freedom to discuss thoughts, feelings and beliefs

49

candidly; (b) a group’s dynamics can generate authentic information; and (c) a
facilitator can help people recover forgotten information or form new conceptual
connections through focusing the discussion and helping participants explore

ideas or impressions in more depth (Morrison & Peoples, 1990).

Data Analysis

Analysis of data was done simultaneously with data collection from
individual and group interviews in the tradition of grounded theory development.
Characteristic of research in this tradition is the constant comparison of data with
emerging categories or themes (Bogdan & Biklen, 1998; Cresswell, 1994;
Merriam, 2001; Seidman, 1991). Transcripts and notes from personal interviews
were analyzed with components of the research questions in mind to determine
emerging common and/or contrasting themes of how participants made the
transition from care giver to case manager. I devised a method of coding
interview data to decipher themes emerging in association with the research
questions I was seeking to answer. For example, I reviewed the ﬁrst interview
transcript and identiﬁed general categories of information that were apparent.
Most of these categories coincided to the interview questions. I did the same
with subsequent transcripts and began to compose a list of categories such as
logistics, work experience, caregiver contexts, case management contexts,
learning experiences, difﬁculties, differences, etc. and labeled interview data
accordingly. I then assembled data frOm each participant according to those

categories and reviewed them for similarities and differences. I was able to

50

compose a list of sub categories. For example, from the data associated with
“difﬁculties” sub- categories included “relationships with adjusters,” “left alone to
learn, “ and “business environment.”

Following the analysis of transcribed interviews, I created concept and
theme listings associated with the research questions that I presented at the
beginning of two focus group discussions. All participants were invited to
participate. Three attended the ﬁrst scheduled discussion, and three others
attended the second. The meetings were held in the conference room of a
centrally located healthcare facility that was made available to us by a
professional colleague of mine.

The purpose of this study was reviewed with participants, along with the
research questions. My impressions of themes emerging from personal
interviews about the nature of role transition for these professionals and how they
learned to function in this new role were also presented and discussed.
Participants either conﬁrmed or challenged these impressions, and offered more
in depth review of some topics. These discussions were recorded on audiotape
and reviewed. Added information was then incorporated in concept summaries
addressing the research questions.

Data reduction was accomplished by the identiﬁcation of themes in
experiences and reﬂections described by individual participants and the
validation of those themes achieved through focus group discussion. I report my
analysis of the data in Chapter Four with descriptions of emergent themes and

patterns of experience. I include case examples that illustrate salient factors in

51

this role transition for participants. Implications of these data in the design and
implementation of case management education and training programs are

explored and presented in Chapter Five.

Delimitations and Limitations of the Study

This study explored the experience of transition between two unique areas
of practice within the profession of nursing by examining interview and focus data
from eleven volunteer participants who have recently made the transition from
caregiver to case manager. Delimitations set for this study are as follows.
Findings reﬂect the experiences of role transition for nurses with up to three
years of experience of case management in one of three work settings. These
three settings are workers’ compensation insurance carriers, case management
vendors, and health maintenance organizations. Data were gathered from self-
reports to garner participants’ personal experiences and perspectives. There
were no intentions in analysis of the data to determine competence of
participants in previous or current roles or personality traits that may have
inﬂuenced their experience of transition.

Limitations of the study associated with sample are the small sample size,
limited geographic area (Midwest state) in which participants reside and work,
and an absence of male representation. While the common and contrasting
themes determined from the data may be useful for educators and trainers in
facilitating the transition for nurses in payer or proprietary case management

settings, some ﬁndings will not necessarily be applicable to nurse case managers

52

in healthcare provider settings or other professions in this or other areas of

practice.

Summary

I conducted a study of role transitions for nurses who have made career
changes from the practice of providing hands-on nursing care to the practice of
providing case management. My inquiry consisted of individual and focus group
interviews of nurse case mangers about their recollections and perceptions of
contextual inﬂuences, experiences and reﬂections on the processes of role
transition and Ieaming. l utilized the methods of qualitative study because it
allowed for in-depth exploration of the interplay between personal, social and
environmental factors addressed in the theories of role transition, situated

cognition, and experiential Ieaming.

53

CHAPTER FOUR - Findings

Introduction

Understanding the process of role transition for nurses who make a career
change from caregiver to case manger should enable nursing educators and
others responsible for developing professionals in this area of practice to design
and enhance education and training programs that comprehensively address
their Ieaming and socialization needs. This chapter will present an overview of
themes emerging from interview data about personal experiences and reﬂections
that are relevant to nurses’ experiences of role transition from caregiver to case
manager. I will ﬁrst brieﬂy introduce participants, who were interviewed for this
study, to provide a frame of reference for the reader. These introductions will be
organized in three groups that illustrate obvious similarities and differences
among participants in terms of current work settings and case management
practice models.

I will then identify those experiences and reﬂections shared by participants
that address the following research questions:

1. Are there characteristic motivations, expectations, sources of role strain and
job satisfaction and learning resources associated the process of this role
transition?

2. What elements of contexts associated with past and present roles are

inﬂuential in this transition?

54

Introduction to Participants

Eleven nurses from three case management practice settings and with
varying clinical backgrounds provided personal recollections and perspectives
about their transition from roles of caregivers to roles of case managers. Table 3
provides demographic information about each participant. Following are brief
narrative introductions to participants that l have divided into three groupings: (a)
participants who practice telephonic CM for a workers’ compensation (WC)
insurance carrier; (2) participants who practice on-site CM for WC insurance
carriers; and (c) participants who practice telephonic CM for health maintenance
organizations (HMOs). These groupings are intended to provide the reader with
information about CM practice settings and CM models that some participants
have in common. (For more detailed information about individual participants,

Appendix Three: Participant Proﬁles.)

Participants Who Practice Telephonic Case Management For A Worker’s
Compensation Carrier.

The ﬁrst group of participants that I will introduce includes four nurse case
managers (NCMs), Ann, Belinda, Ginger and Irene, who are employed by a
national workers compensation (WC) insurance carrier. They work in an ofﬁce
with 8 other NCMs and 25 — 30 claim staff, and carry out their case management
(CM) responsibilities telephonically. Ann and Ginger had shared experiences in

previous work settings, as did Belinda and Irene. All four currently report to a

55

Table 3. Participant Demographics

 

NCM

Ann

Belinda

Age

53

49

Ed

BSN,
MA

ADN

Yrs as
Cgr

30

Clinical Contexts

Critical Care units

Emergency room

General Practice
clinic

Skilled Nursing
facility

General Practice
clinic

Pediatric clinic

Yrs as
NCM

1.5

CM

Contexts

WC
Carrier

WC
Carrier

CM
Model

Tele-
phonic

Tele-
phonic

 

Girger

Irene

Donna

Hannah

Cathy

53

46

41

29

BSN

BSN

ADN+

BSN+

BSN+

30

21

21

14

Critical Care units
Emergency room
Medical Surgical
units
Pediatric clinic
Emergency room
General Practice
clinic
Occupational
health clinic
Orthopedic unit
Oncology unit
Home Care
Medical/surgical
units
Oncology unit
Public Health
clinic
Home Care

1.5

1.5

WC
Carrier

WC
Carrier

WC
Carrier

CM
Vendor

CM
Vendor

Tele-
phonic

Tele-
phonic

On-site

On-site

On-site

 

Judy

Karen

43

ADN+

BSN

20

Medical Isurgical
units

Home Care

Medical/surgical
unit

Orthopedic unit

Home Care

Utilization Review*

1.5

1.5

CM
Vendor

HMO

On-site

Tele-
phonic

 

Fran

Evelyn

47

ADN

BSN-I-

1O

29

Medical/surgical
units

Pediatric unit

Critical Care units

Obstetrics and
gynecology unit

Emergency room

Utilization Review*

Pediatric unit

Pediatric clinic

Public Health
clinic

56

HMO

HMO

Tele-
phonic

Tele-
phonic

Note: Shaded areas indicate coworkers; NCM = Nurse case manager; Ed = Education; ADN =
Associate Degree in Nursing; BSN = Bachelor of Science Degree in Nursing; MA = Master of Arts
Degree; + = additional coursework; CM = Case management; WC = workers’ compensation;
HMO = Health maintenance organization; * non care giving role

supervising NCM, as well as a claim department team leader. They share
caseload responsibilities with adjusters. All four indicated that the adjuster has

the ﬁnal authority on claim handling decisions.

Ann.

Ann came into her current role as an NCM from 30-year background in
emergency and critical care nursing. She made this career move primarily for
health reasons. She needed an occupation that was less physically stressful
than her role as a caregiver in the hospital. Ann became aware of case
management as an employment option through a personal friend who worked for
her current employer. When an open position coincided with her health
difﬁculties, Ann made the move. She views case management as “more laid
back” than care giving. She notes that CM creates “stress in its own way,” for
her, but she feels “it’s a good way to end a career."

Ann enjoys contact with the employers insured by the company, the
patients and the physicians. She struggles at times with her relationships with
adjusters, however. She remarks, "[The adjusters] are in that world and [the
nurses] are in the medical world and there is a deﬁnite distinction." She ﬁnds
having to relinquish authority to adjusters on medical claim decisions to be very

frustrating.

57

 

 

and Cl
was fi
Ann 1
poslh
back
telep
that :

unde

thou
lreal

This

enjo
incor
Oian
9mph
in ped

We of

Ginger.

Ginger also came into the case manager role with signiﬁcant emergency
and critical care nursing experience. Her motivation to make a career change
was fueled by dissatisfaction with changes in the hospital setting. Knowing that
Ann was satisﬁed with her change, Ginger asked to be considered when another
position was available. Like Ann, Ginger ﬁnds this career alternative more laid
back than hospital nursing. But unlike Ann, Ginger does not ﬁnd her role as a
telephonic case manger to be a good use of her knowledge and skill. She opines
that a nursing background is not really required to accomplish what she
understands her job to be.

Her job preference would be to teach in some capacity. She admits,
though, that she does have opportunities to provide education about things like
treatment options, post-surgery care, and WC coverage issues to claimants.

This is when she recognizes the merit of a nursing background in CM.

Irene.

Irene sought alternative employment from a pediatric clinic, where she
enjoyed considerable job satisfaction, because of the need to enhance her
income. Faced with supporting herself following a divorce, Irene took advantage
of an open position made known to her by a personal acquaintance who was
employed with this WC insurance carrier. Realizing that her clinical background
in pediatrics would most likely be viewed as insigniﬁcant in qualifying her for the

role of a WC case manager, she was nonetheless determined to secure the

58

position for the ﬁnancial advantage it offered over her salary potential at the
clinic.

Of all participants, perhaps Irene struggles the most with reconciling her
professional identity as a nurse with her role as a WC case manger. Though she
believes she has gained signiﬁcant knowledge, skill, and conﬁdence in her ability
to assist injured workers to obtain appropriate and effective healthcare, she
resumed her connection with the pediatric clinic on a part-time basis. Every
Sunday she provides telephone triage services for patients of the pediatric
practice that previously employed her. Irene ﬁnds that this keeps her tied to
something she ﬁnds truly worthwhile. She proudly shares, “I have moms now
that only call on Sundays because they know I’m going to be there on Sundays.
So you build up that what they expect of you is peace of mind, not so much the

actual care giving, but the mentoring shall we say?”

Belinda.

Belinda’s clinical background is also primarily in pediatrics, gained in two
different clinic settings. Her motivation for making a career change to CM was
fear that a change of ownership of the clinic would ultimately result in elimination
of her position. She became aware of an open case management position from
Irene, who had made this career change earlier and whose employer was
seeking to add to the case management staff.

Belinda feels that case management has provided her with opportunities

to grow professionally as well as personally. She has learned about a myriad of

59

injuries and treatment options not encountered in a pediatric practice. She has
found a new resourcefulness in looking for information, networking with others
and taking advantage of in-service education and training programs. She has
gained conﬁdence in questioning or challenging physicians.

She grieves for the “warm, nurturing, [give] me a hug and I’ll make you
feel better kind of a caregiver" she used to be, and yet she has learned to
respond to people from a more realistic, objective perspective where she is able
“to pick up the facts and deal with them as they sit there.” The more she has

learned in the role of case manger, the more interesting it becomes for her.

Participants Who Practice On-Site Case Management For Workers’
Compensation Caniers

The second group of participants I will introduce, Donna, Judy, Hannah
and Cathy, practice on-site case management for WC insurance carriers.
Though many of the contacts they make in the course of their practice are by
phone, they routinely make ﬁeld visits to hospitals, physicians’ ofﬁces, claimants’
homes and job sites in order to establish rapport, make comprehensive
assessments, and monitor progress. Donna is employed by a national WC
carrier. Judy, Hannah and Cathy are employed by CM vendors that contract with
WC, auto and disability insurance carriers for CM services. Cathy and Hannah

are coworkers.

60

Donna.

Donna reﬂects that her move into case management is the most recent in
a series of job opportunities that play out like “stepping stones”, each providing
her with skill and direction for a logical next move. She gained nursing
experience in a variety of clinical settings, including emergency nursing, out-
patient clinic administration, and occupational health. She credits each of these
experiences with contributing to her interest in and understanding of job related
injuries from perspectives of the injured worker, the healthcare provider and the
employer.

The major source of role strain for Donna is managing time in the ﬁeld with
time sensitive clerical tasks such as dealing with mail, ﬁling, documentation and
time logs for billing. She is most in her element interacting with injured workers,
physicians and employers. Though she has been provided with supplies and
technology with which she can work from her home, she admits that she
continues to struggle with problem solving around that technology and organizing
a workspace in her home. She views these expectations of her role to be
unnecessary burdens that tax her efﬁciency and effectiveness in performance of

her primary CM responsibilities.

Judy.
Judy is employed by a local CM vendor. She moved into CM from the
ﬁeld of home care where she found dissatisfaction with increasing regulations.

Though her experience in home care introduced her to the concept of working in

61

the ﬁeld and managing a caseload, she found the transition to CM to be
somewhat of a challenge in understanding the NCM/adjuster relationship, that is,
knowing what the adjusters expected from her. As an employee of a CM vendor,
Judy understood that her case assignments were contractual and that business
for her company came from insurance claim adjusters who needed help with
managing expenditures on injury claims. She struggled, however, with how to
impress claim adjusters with her "helpfulness" in managing medical expenditures
when she was not yet conﬁdent in her ability to do so. She felt that she lacked a
comprehensive understanding of the case management process and that her
employer had unrealistic expectations that she should be able to tailor her
interactions with adjusters in order to promote her value and garner more

referrals while she was Ieaming the job.

Cathy.

At 29 years of age, Cathy is the youngest participant who provided data
for this study and also the participant with the least number of years of prior
clinical experience as a professional nurse. In addition to hospital and home
care experience, Cathy worked for a cancer treatment center providing patient
education, and at a county Health Department following patients exposed to or
diagnosed with tuberculosis. Cathy chose case management as an employment
option in her search for a good way to use her university education. Her initial
experience on an oncology unit in a hospital was not sufﬁciently challenging for

her. Responding to a newspaper ad, she was called to interview for this case

62

 

 

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management position. Through research on the Internet, and conversation
during her interview, Cathy realized she had developed some case management
skills in her previous jobs with the Health department and the cancer treatment
center. She is pleased with the type of challenge CM has provided. “Here it’s
more coordination, a lot different. Different time frames to be dealt with, reports to
be written, a lot of communication with various people- attorneys, doctors,

accounts.”

Hannah.

Hannah brings four years of hospital nursing experience on oncology and
orthopedic units as well as ten years of home care experience into the role of
case manager. Like Judy, Hannah found Medicare regulations to be affecting the
way she was able to practice nursing in patients’ homes. Disillusioned with the
politics and ever increasing paperwork required for home care providers to be
reimbursed by Medicare, Hannah followed the lead of a former coworker who
found satisfaction in case management. Though she had some preconceptions
of the difﬁculties she might encounter in managing workers’ compensation cases
in terms of dealing with claimants reluctant to return to work, she found the reality
not so grim. She perceives CM as an effective way to bridge the communication
gap that occurs frequently in the healthcare system among providers, patients

and payers.

63

Participants Who Practice Telephonic Case Management For A Health
Maintenance Organization

The third group of participants includes Fran, Karen and Evelyn, who are
employed by health maintenance organizations (HMOs). An HMO is a medical
beneﬁt plan that both provides and pays for healthcare. Plan members (patients)
are limited to providers within a network, and network providers are expected to
practice according to speciﬁc care models or protocols. Nurse case mangers are
employed to oversee the health care needs and service utilization of members
whose medical proﬁle meet certain criteria, like a particular disease entity, or a
certain dollar amount of ﬁnancial exposure for the insurer. These NCMs practice
telephonic CM with some occasional on-site opportunities.

Fran and Karen are employed by the same HMO. Both have come into
case management with experience as utilization reviewers in addition their
respective clinical backgrounds. Utilization review (UR) is a process that certiﬁes
the medical necessity of prescribed treatments, procedures, and hospital days, in
an attempt to address over or under utilization of services. Initially UR was a
method employed by health insurance carriers to hold physicians accountable for
what they prescribed for patients and control costs. Hospitals adopted the
practice of UR internally to avoid incurring costs for healthcare services that
would eventually be denied by third party payers. Fran describes the difference
between UR and CM in the following way. “Well, I joke around, but I say a UR
person gets them out of the hospital and a case manager keeps them out of the

hospital. So really, that’s the difference to me...”

64

Fran.

Fran’s clinical background was established on various hospital units over
10 years time. Medical specialties that she became familiar with during that time
include internal medicine, general surgery, pediatrics, intensive care, obstetrics
and gynecology and emergency medicine. She left bedside nursing for a
position in utilization review because it offered an opportunity for growth, to gain
some new perspectives. It was this transition that introduced her to the
“business part” of healthcare. In the role of case manger, she follows a caseload
of members with chronic diseases. Many of the members she follows are senior
citizens. Fran practices a combination of telephonic and on-site CM. Her primary
source of satisfaction In this role is assisting members navigate through a

complex healthcare system in order to gain access to needed services.

Karen.

Karen’s clinical background includes 15 years of hospital nursing and
home care. A back injury precipitated her search for employment options other
than physical care giving. She made the transition to case management after a
series of positions including discharge planning and UR in the hospital setting.
Her move to case management at the HMO was precipitated by dissatisfaction
with the hospital environment. In fact, she increased her commute and took a
pay cut in order to escape an environment that was causing her considerable

stress.

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Karen practices principally telephonic case management, though she has
the option of meeting with members either in their homes or during physician
appointments. She ﬁnds her caseload unwieldy, however, and believes that
there is just not enough time for ﬁeld visits. Her role as case manger has
provided Karen with opportunities to become proactively involved with members
Ieaming to live with chronic disease. She enjoys the patient interaction and the

opportunities to Ieam new things.

Evelyn.

Evelyn is a pediatric NCM with a different HMO. She is responsible for
managing the healthcare of premature babies and children who have illnesses or
injuries that are considered catastrophic. Coming from an extensive pediatric
clinical background including hospital units and clinic settings, Evelyn feels quite
conﬁdent in her ability to make considerable impact in helping families deal with
signiﬁcant health issues involving their infants and children, as well as to contain
costs for her employer. She came to this position as a result of looking for an
alternative to her job as a nursing supervisor at an ambulatory care clinic.
Budget cuts and reorganization placed considerable stress on the clinic
resources left to carry out work. An ad in the paper for a Pediatric Case Manager
caught her eye. Not knowing exactly what the role of case manger entailed,
Evelyn knew her background in pediatrics would give her an advantage in

securing the position. She feels this has been a good career move, and that she

66

is supported by her colleagues and supervisors in providing an important service

for HMO members.

Characteristics of the Transition from Care Giver to Case Manager
The ﬁrst research question in exploring the transition experience of nurses
who have made a career move from caregiver to case manger addressed here
is: Are there characteristic motivations, expectations, conﬂicts, sources of
satisfaction, and Ieaming experiences associated with this transition? This
section will demonstrate similarities and differences in each of these areas that

emerged from personal interviews and focus group discussions with participants.

Motivations

Most participants shared that the motivation for making this career change
stemmed from dissatisfaction with their current work situations. Rather than
aspiring to become a case manager with a true appreciation of what the role
entailed, most participants explained that a position in case mangement offered
them an alternative to work conditions they could no longer tolerate. These
conditions included (a) long hours and inﬂexible work schedules, (b) low
staff/high patient ratios, (c) policy and regulation changes that impacted care
giving practices, (d) job insecurity (e) inadequate compensation, (f) physically
taxing duties, and (g) inadequate intellectual challenge.

The hospital setting was described as undesirable because of the long

hours and inﬂexible work schedules that routinely included weekends and

67

holidays. While many nurses enjoyed providing care, the low staff/high patient
ration prevented them from delivering the kind of care they felt the patients
needed. Some participants felt uncomfortable with the excessive volume and
scope of their responsibilities while on duty which increased the risk of
malpractice and ultimately placed their nursing license in jeopardy.

Ginger and Ann, for example, felt over burdened with professional
responsibilities in the hospital setting on the one hand, and yet uncomfortable
with the type of tasks being assigned to under-qualiﬁed personnel to make up for
staff and funding shortages on the other hand.

It just got so stressful...l really liked what I was doing, and I felt like
I was good at it. I really did enjoy the hospital setting and I miss
that. I miss that acute care aspect of it. I miss the patient contact.
But they started cross training people and eliminating positions.
Like ﬁrst it was the lab techs, and then the nurses did all the blood
drawing. Then the next thing was the EKG tech, and slowly but
surely adding more and more patient load on you and additional
responsibilities. I was working three 12 hour shifts a week on the
day shift, 7am to 7pm, and there [were] many, many times when
you just weren’t getting your breaks and what have you...The
situation involved a position where you just could not leave. I mean
you were tied to that, and if you didn’t have a relief [person], you
know, that was it. So it just became more and more stressful to
me, not taking breaks and whatever, and that’s basically why I got
stressed out -not because I got fed up with the job itself. I really
liked the emergency nursing. I probably would still be at the
hospital if it weren’t for that. (Ginger)

They are letting people do procedures. Like you have aides that
are being trained to do things that I don’t feel comfortable [with]
them doing. And it would be under my license, and I worked too
hard to keep my license for thirty years. And that was one of the
major reasons too I left. I was having aides telling me what to do,
and I’m the nurse. Not that I’m greater than them, but it’s my
education and my license and it’s one of the other reasons I left.
(Ann)

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Though Karen left her role as a caregiver initially due to a back injury, she left her
role in utilization review in a hospital setting because she too felt over-utilized.

I had had it with hospitals. I want to do something different... I’m
weighing sanity verses less pay, but ...a different outlook, a
different something to do. I was putting in 10 to 12 hours on my
feet all day no lunch and leaving the hospital exhausted... We
were doing discharge planning and utilization review, so we were
reviewing charts. We were on our feet all day. There was nowhere
to sit to review ...you could review lots of different units or you work
one unit. Now I’ve learned they’re just keeping people on one unit,
which I think is a much smarter thing to do. But at that time we
weren’t. In addition to doing that you would do a discharge plan, so
you were trying to get people out the door at the same time... I just
wanted a change. I want to do something different. I really felt like
I was going to be committed if I didn’t do something different.
(Karen)

Judy and Hannah cited changes in Medicare regulations as fueling their
motivation to leave their positions in home care. They described these what they
saw as sudden changes that signiﬁcantly impacted their practice and ultimately
their job satisfaction.

Pretty much home care was not regulated, and then all of a sudden
it became regulated and it caused a lot of turmoil and strain... It
got very political. There were a lot of changes. Medicare made
some huge changes that affected things. When I worked at visiting
nurse people worked there for years and years. All of a sudden
people were starting to leave and go into different roles. They
weren't’ happy with the environment. (Hannah)

Home care was different because of the regulations you were
under with regard to Medicare. Those were very strict
regulations... When I ﬁrst started in home care there was quite a
bit of leeway to take. It seemed like you were able to do more to
make sure things were good for the patient than there is now
because the regulations in home care now is you admit them and
discharge them as quickly as possible...lt’s much more geared
towards hurrying up, do it as cheaply as possible. (Judy)

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Two participants’ who left clinic settings for CM positions identiﬁed their
motivations for making the transition as a need to enhance income and a fear of
impending position reductions. Irene and Belinda both had several years of
experience in pediatric clinics and enjoyed working with children and providing
support and advice for parents. After her divorce, Irene required more income
and beneﬁts than a position at a pediatric clinic offered. Though she was very
satisﬁed with her role as a pediatric nurse, she found CM to be a more lucrative
alternative.

It was very emotional for me. I absolutely loved my clinic, and for

socio-economic reasons I had to. I was divorced after 30 years and

I had no pension or any of those kinds of things available to me so I

knew I had to do something else that was going to take me into my

retirement. So it was a very, very difﬁcult thing for me to give up

my pediatrics and go into case management. I like it now. I don’t

love it. I like it. I think I’m pretty good at it. I’ve gotten a conﬁdence

and that kind of thing. I’ve gotten a raise every year. But I’m here

because I have to be. (Irene)

Belinda followed Irene into a CM position with a WC insurance carrier because
she feared the loss of her job at a pediatric clinic. As a single parent, she found
the higher salary to be an added bonus to what she hoped would be job security.

Basically the whole thing happened because one of the major

hospitals in town was experiencing a money problem...They

happened to own the practice I worked for, and the rumor came

down that anybody who was more than a nurse’s aide was being let

go because they weren’t going to pay the nurses to work in a

doctor’s ofﬁce anymore. And that actually did happen to one of the

other people that I worked with there and it scared the heck out of

me. (Belinda)

Fran and Cathy were the only two participants in search of a more

stimulating occupation when they made the transition to CM. Fran explained her

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reason for moving from the role of caregiver was a desire for more ﬂexibility in
her employment options. She felt that her moves ﬁrst into UR, then to CM,
expanded her capabilities. Cathy, found a CM position in pursuit of a more
intellectually stimulating career.

When I got out of nursing school I was a little bit upset by the fact

that when l was in the hospital I felt as though I didn’t really need to

go to university for doing what I was doing there. You know, I felt

that anybody can come here and follow the instructions, follow

these orders that the doctors are writing in this little book. And

anyone can give this. Anyone with any kind of, you know, because

you don’t have to be educated to do this. And I was upset by that.

(Cathy)

Though participants’ motivations to make the transition from caregiver to
case manager varied, most shared the characteristic of being fueled more by a
desire to ﬁnd a port in the storm, so to speak, than a desire to advance in their
nursing career. Looking to improve the conditions of employment, most
participants were willing to take a leap of faith that even the unknown aspects of

the case manager role would be more tolerable than the undesirable aspects of

previous roles.

Expectations

Participants’ expectations about the role of case manager were closely
tied to the promise it held for providing relief from the undesirable conditions of
the roles they were exiting. These expectations included (a) more ﬂexible work
schedule, (b) less physically taxing job responsibilities, (c) manageable

workloads, (d) opportunities to utilize nursing knowledge, (e) better

71

compensation, and (f) job security. These expectations were fed by second hand
reports most participants received from personal friends or professional
acquaintances that alerted them of open case manager positions while they were
contemplating making a career move.

Ann and Belinda and were approached by friends who alerted them to
open positions and encouraged them to apply. Irene, Donna, Ginger, Judy and
Hannah stumbled on open positions through conversations with professional
acquaintances. Evelyn and Cathy saw ads in local newspapers, applied for the
positions out of curiosity, and were informed about the role in their job interviews.
Fran and Karen, knowing that case management was an employment option that
they wanted, submitted resumes to an HMO asking to be considered for an
interview when a position opened up.

At 56 years of age, Irene was desperate for employment that offered a
suitable compensation package that would help her prepare for retirement.
Although she was conﬁdent that her current position with a WC insurance carrier
would provide her with that, she admitted that she did not have a comprehensive
knowledge of what would be expected of her in the case manager role.

I don’t know what I thought it was going to be. I just took it.

Somebody told me, ”Hey it’s not bad. Do it." I mean I feel like I can

do just about anything. So I tried it.... I don’t think I really knew

what I was getting into, but I think just the word case management -

I ﬁgured I could probably do it cause I’m a pretty good manager.

And I’m a good manager of my time and I know I can talk to people

and I can relate. (Irene)

Judy was looking to escape the burdensome Medicare regulations she

encountered in home care. At the same time, she was enrolled in an accelerated

72

graduate nursing program and hoping to eventually advance her position within
the ﬁeld of nursing. She acted on an opportunity to move into case mangement
with a CM vendor without much prior knowledge of what the job responsibilities
were, or how adequately she was prepared to fulﬁll the expectations of her
employer.

I had no clue what a case manger was, no clue. I had gotten into

this nursing administration master’s program thinking that I would

be in management. And I wasn’t sure. I’d considered an acute

care nurse practitioner. I ran the gambit of what I was going to do

with nursing. I just knew I had to get out of home care and out of

that ﬁeld nurse thing I got tired of that. So anyway what happened

is when I was a supervisor in home care, someone, a case

manager, called me about one of her clients. And it was a woman I

had worked with years before in home care and she started to tell

me about what her job was like and what she did. And it just

sounded like perfect. (Judy)
She also shared that her graduate nursing program had nothing to offer in the
way of scheduled courses or independent study in the ﬁeld of case management.

Donna had some interaction with NCMs in her role as an
occupational health nurse. In this role she gained exposure to work
related injuries and often communicated with WC insurance claim staff,
some of who were adjusters and others who were NCMs. This provided a
basic awareness of the WC claim process and, to a limited extent, the
case manager's tasks. Even so, she was not aware of the expectation
that as a case manger she would need to log her activities and be held
accountable for a certain number of billable hours.

Well, I knew that case managers went on appointments. And I

knew they made calls back to the plant, the employer. And I knew
there were forms that they would send me as far as getting the

73

information, so there was a communication. I knew about the
communication. I knew about the visits. I didn’t have a clue about
the billing, and that to me is like, what do you mean nurses have to
bill? You have to bill your work? That was like ’Wait a minute!" I
wasn’t expecting or prepared for that. (Donna)

Karen and Fran, both having had experience in UR and discharge

planning in a hospital, had the most familiarity with the case manger role. They

submitted resumes without seeing an ad or having knowledge of a job opening.

To them, CM seemed like the next logical step. Karen admits though that her

expectations were not entirely consistent with what she is encountering on the

job.

Knowing that discharge planning and UR was part of case
management, I thought [I] might have a shot at it - because I knew
those were components of case management. But I guess what I
expected when I came to [this HMO] is this is what case
management is. But I have learned is that case management is a
growing body of knowledge that isn’t set in stone, and We as
case managers, along with it , we’re learning what it is . And I’ve
got a new case manager who’s just come to us a couple of months
ago and I said that to her, ’We’re all learning this together, we really
are." (Karen)

Entering the role of case manager with expectations that it would provide

relief from undesirable work situations and opportunities to utilize their nursing

background, participants were generally not aware of aspects of the case

manager role that might prove to be problematic for them or aspects that would

provide them with opportunities to grow and develop professionally.

74

Sources of Role Strain

Hopeful that the role of case manager would fulﬁll their respective desires
for better work situations, participants explained that there were a number of
work situations that they did not anticipate and that their knowledge and
experience as caregivers did not necessarily prepare them for. Feelings of
inadequacy or incompetence associated with these situations contributed to role
strain. These situations appeared to center around four major themes: (a) time-
task orientation, (b) interactions and relationships, (c) business culture and
objectives, and (d) professional identity and self-image.

Nurses entering the ﬁeld of case management directly from hospital
settings did not anticipate the need to accommodate their time-task orientation to
ﬁt the role of case manager. Managing cases over an extended period of time as
opposed to completing care required by assigned patients on an eight or twelve
hour shift contributed to role strain for new NCMs. In care giving contexts, the
scope of task accomplishment was on administering prescribed care within the
timeframe of a daily shift. Patients were assigned or scheduled on a daily basis.
This assignment could vary from day to day. Alternate staff was scheduled to
work on subsequent shifts or days so that work did not routinely accumulate in
their absence.

In contrast, participants described the scope of task accomplishment in
the case management context as scheduling and implementing a series of tasks
over time to effect longer term objectives. While routine accomplishment of

some tasks is expected within certain timeframes, such as initial contacts with

75

patients, providers or employers, the on—going tasks of case management are
seen as more strategic and timeframes more discretionary.

Ann, who had worked for many years as a caregiver in emergency rooms,
found the need for a major shift in her inclination to respond and complete task
assignments immediately to a planned approach of managing a series of tasks
strategically over time.

I was used to having to do X number of things done before I went

home, and here...when I ﬁrst started, ifl had a red number on my

[computer diary] screen which meant that these were things that I

should have done already, I was like hysterical. “Oh my god! I’ve

got to get these done.” Because I was in that mind-set that you

don’t go home till this is done. You know, you have to get your

charting done, and give your meds, and make sure that patient was

cleaned up before you went home. Well here it was like “Oh, ok.

So I’ll just do it tomorrow”.... I had to learn that l was setting my

own diaries and I could set them for however long I wanted to. So,

[if] a person is being evaluated today [by his or her physician]... I

was setting diaries for like the next day [to work on the ﬁle]. Well

no, ’cause nobody’s going to know anything [yet]. So set it for next

week. (Ann)

Ginger, who had an extensive background in emergency and critical care
nursing struggled with the need for a sense of closure and accomplishment as a
new NCM. In the hospital she worked long, intense hours, often without breaks.
Even so, at the end of her shift, she knew her work was complete and would not
carry over to her next scheduled day on duty. As a case manager, she has to
deal with a progression of tasks associated with each case assignment that
extends over days, weeks and even months. This has forced her to Ieam new

strategies for prioritizing and managing time.

You know, it’s like the kind ofjob that I do now, it’s never done. It’s
just a continual day-to-day thing where it’s not the same kind of

76

expectations. I mean you’re still a professional. You’re still

expected to... you know, work according to guidelines. You have

expectations given to you, but it’s not in the same capacity, I

wouldn’t say....so once I started doing my own caseload it got more

comfortable. Then as the numbers got higher and I got a higher

caseload it got very frustrating. . .. But I had to get over that, feeling

like you’re not killing anybody here ...you’re going to get caught up

and if you have to, ask for help. (Ginger)

The autonomy afforded NCMs with designing their own system of
managing tasks and time can also contribute to role strain. Donna, an on-site
NCM employed by a WC insurance carrier, has an ofﬁce based in her home.
She has to organize her work day to accomplish not only the appointments she
has made with claimants at their homes, in hospitals, at physician ofﬁces, or with
their employers, but also to complete time-sensitive ﬁle documentation and
manage a number of other clerical tasks without any administrative support. Her
background in emergency nursing, occupational health and out-patient clinic
administration did not prepare her for this.

Maybe it’s because I’m still new, I feel like there's so much that I

didn’t get to today. And I don’t know if that’s typical, whether

you’ve been in it for 4 years or if it’s because I’m still trying to

sharpen my pencil as a case manager. ...[l’m] starting to eliminate

the little things that I don’t necessarily need to do. What about

working in the ﬁeld? Just the nature of working in the ﬁeld and

becoming organized, you know, when you have that much ﬂexibility

in your day. (Donna)

The care giving experience, particularly for those participants who worked
In hospital settings and to a lesser extent clinic settings, created an orientation to
time and tasks associated with structure and a sense of urgency. This time-task
orientation, which served to focus nurses’ attention on immediate healthcare

needs of patients, was a necessary part of nursing judgment and clinical skill that

77

they had developed over many years. The need to change this orientation in
their new environment was an aspect of the case manager role that they did not
expect and that contributed to a feeling of incompetence.

The second theme associated with sources of role strain in the transition
form caregiver to case manager is interactions and relationships. Interview and
focus group discussion data suggest that new NCMs were confronted with
unanticipated dynamics in their interactions and relationships with patients and
physicians, and uncharted territory in interactions and relationships with non-
medical colleagues, speciﬁcally claim adjusters.

In the role of case manager, nurses learn that ill or injured parties are not
only patients in the sense that they require healthcare services, they are also
“claimants,” or in the context of an HMO, “members” of the plan who are also
seeking ﬁnancial support for those services. Available ﬁnancial beneﬁts
associated with illness or injury creates added dimensions to nurse-patient
relationships for case managers. The issue of trust in their relationships with
patients is one of the ﬁrst hurdles most participants had to clear.

Dealing with patients who lie to secure ﬁnancial beneﬁts, or malinger to
avoid work responsibilities created discomfort for NCMs who manage WC,
disability or automobile injury cases. They reported emotions from surprise to

disgust in encounters with patients who would fabricate or embellish an injury.
Belinda commented on how na‘ive she felt after her ﬁrst few encounters with WC

claimants who were less than truthful about circumstances surrounding their

78

injury or progress in recovery, and how that affected her approach in subsequent
contacts with claimants.

People sounded nice to you on the phone, sounded sincere. You
got them into the doctor. You got them everything that you knew
they should be getting for this particular thing, and they still weren’t
better. And then they called me every morning at 7 o’clock. “ I’m
hurting and I’m in pain.” And the ﬁrst couple of times [I believed
them]...and then I ﬁnd out that they’re at the bar with all of their
friends and they’re dancing and this one sees them there, and
that one sees them there. And you think, oh my god! I sat on the
phone every day for three weeks listening to this lady tell me how
awful her life was and putting it in the ﬁles. This poor lady has so
much trouble. And like I said, then you read the surveillance report
and you think, oh god, how could I be so dumb, so dumb? And it
was more than one thing like that but I would say within the ﬁrst 6
months you ﬁgured it out - probably the ﬁrst 3 months. The ﬁrst
time you get somebody who plays you like that, you think, you
know, ...I can’t do this. Nobody’s going to do this to me again.
And you go the other way and then you don’t trust anybody, and
then somebody will come along, “Well you know, ...it really hurts.”
And you’ll think, “Oh come on.... Give me a break!” And you
eventually send them to a doctor and they have a broken wrist.
And you feel really bad and you say, “Oh gosh, I’m sorry.” And
you ﬁnd that middle ground. You ﬁnd that middle ground where
everybody starts out basically the same and until they prove
otherwise. (Belinda)

Establishing rapport with patients who are mistrustful was also unexpected
and a source of strain for new NCMs. Participants felt that their association with
insurance companies often affected patients’ perception of them. Judy, whose
care giving background was in home care, noted a difference in the ease with

which she could initially establish rapport with patients. "[In home care] there
wasn’t that self protective mode in your contact with them. [In CM] they’re

protecting themselves from you, almost.”

79

Building rapport despite this initial distrust required learning strategies to
“get a foot in the door.” Evelyn explained how she changed her approach on
introductory telephone calls after several encounters with wary parents of the
pediatric population she served.

You can hear it in their voice when I call and I say my name is
[Evelyn] and I’m a case manager at [this HMO] and ....[they
answer] “....yes?”... You know what they’re thinking, “Why is
someone from the insurance company calling me?“ So I learned a
long time ago not to say “I’m calling from [this HMO], a case
manager.” [I now say] “My name is [Evelyn]. I’m a pediatric nurse. I
work for [this HMO] and I’ve been doing [pediatrics] for twenty
something years.” Then they loosen right up. (Evelyn)

New NCMs also experienced discomfort around their role in legal issues
associated with insurance claims. Not being versed in regulations governing
WC, automobile injury protection, disability and health insurance, they were often
fearful of making a mistake in handling a case that would contribute to an
unintended advantage or disadvantage to either party (the claimant or the
insurer) if legal action ensued. This also created another dilemma in their
relationships with patients, which is balancing advocacy with prudence. Cathy,
who works for a CM vendor, found a surprising need to consider diplomacy in her
communications.

To me it seems that in case management you have to learn

diplomacy because of a lot of the things that you’re dealing with

may be in litigation. There may be litigation going on here, litigation

going on there, certain insurance laws that I don’t know because I

have never worked in insurance. But I ﬁnd that sometimes I have

to be careful in the way I put things. I cannot be as straightforward

as I’m used to being. I have to be a little bit sideways. So in that

way I’m not very prepared for that. That’s something that I’m really

trying to work on. For example in situations where there’s
surveillance going on or when somebody may be doing some

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symptom magniﬁcation or something like that... l have to be careful

how I should say that or whom I should say that to, howl should

write it in a report - how I should write things, how I shouldn’t write

things in this way. (Cathy)

In their role as case manager, nurses encountered added dimensions with
their relationships to patients that care giving had not necessarily prepared them
for. In this context, patients had the added interest of securing ﬁnancial beneﬁts,
and new NCMs had the added interest of protecting their employers from undo
ﬁnancial exposure. These factors plus the notion that their relationships and
interactions with patients could impact any ensuing legal actions associated a
claim for beneﬁts were considerable sources of role strain for new NCMs.

Working in a different context with physicians contributed to role strain for
some NCMs in their transition from care giving. They were not accustomed to
discussing treatment options with physicians or questioning their rationale for
continuing treatment. Cathy and Belinda, for example, were uneasy about
approaching physicians on a more collegial level, having been socialized to view
them as the ultimate authority on all health-related issues or ”the boss” in prior
jobs.

I think another difference is in the hospital you’re basically...giving

a doctor a situation. “Doctor, her blood pressure is elevated,” you

know, and he will respond by ordering the medication and you will

carry it through. Here very often you’re not just giving him a

situation, but you’re also sometimes asking him to justify the

reasons behind his treatment, choice of [one] treatment as opposed

to another one, you know. If there’s an injury and he says, “I’d like

to go without this,” you might ask, “Doctor, you know, is there a

reason why you don’t think that this is a good idea?” Which in a

way you’re asking him to justify that, and that’s a very different thing

for me to get used to. It was very difﬁcult for me to get used to.
(Cathy)

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I’ve worked for them [in the clinic]. You are an employee and
basically you do what you’re told. And there is a lot of that old
school nursing thing that comes in there. I know that l have friends
who have graduated from nursing school 10 or 15 years later who
look at me like I’m crazy, you know. “You actually made coffee for
them?” And we’d just look at them and go “Well of course you do.
God! They’re the doctor[s].” So it’s perception in your own head
and it’s just understanding that they have knowledge that you don’t.
And also that inability, not quite accepting the fact that [a doctor]
would order something, be it a surgery or whatever because the
patient wanted it, and not because they needed it. And once I
realized that that actually does happen, it was a lot easier for me to
say [to a doctor] “Well, wait a minute!” (Belinda)

Ann's difﬁculty in relating to physicians in this new context stemmed not
from the need to question or confront them in her role a case manger, but rather
how to build rapport and establish credibility over the telephone.

In the hospital we are directly [relating] with them. You’re on a
face-to-face most often, or they know you. You know them. In
[telephonic CM] you're dealing with physicians all over the nation.
I’ve got them all over the nation, and they don’t know you, so you
don’t have that personal rapport like you do in the hospital. So they
have to get to know you and what you’re expecting and that when
you say “this is black,” they have to believe you like in the hospital
they do. It was to the point in the hospital, working in the same
facility for so many years, that when I would call [the doctor] back
and say, “Look this patient needs this,” he would say, “Oh. OK,
[Ann]. Go ahead. Where as these physicians don’t know me, and a
lot of times they’re like, don’t want to be bothered because you’re
just a case manager- what do you know? (Ann)

Approaching physicians with a posture of conﬁdence and credibility and
gaining their trust is a tall order for new NCMs whether they practice on-site or
telephonic CM. Successful strategies developed and used In relating to
physicians as caregivers do not necessarily provide new NCMs with the

knowledge and skill required to interact effectively with physicians as case

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managers. However, Donna, who had opportunities to relate with physicians in
her previous role as manager of an industrial plant health clinic, did not ﬁnd
interacting with physicians on a collegial level to be difﬁcult.

In the plant setting, when I sought out [an outside] clinic, lwasn’t
necessarily a nurse. I was more of a manager, and I’m assessing
[the services provided by the physician in the clinic], so it was a
little different. It wasn’t like the hierarchy of a doctor to a nurse. It
was more like, ”VIﬁll you meet our needs?” I think I’ve always
learned to confront the physicians through the roles that I’ve had,
and so in case management when you confront these physicians...
I don’t know how I even learned it, but I don’t feel uneasy, and I
don’t feel unpolished, and I don’t feel insecure. (Donna)

Donna, along with a number of other participants, shared her frustration
with interactions and relationships with adjusters. She experiences difﬁculty at
times with convincing adjusters of the merit of her medical perspectives on
claims and also has trouble understanding the adjusters’ objectives and priorities
in claim handling strategies.

I’m more intimidated by adjusters than I am by physicians...
because I don’t think [some adjusters] truly understand the situation
what goes on in a doctor’s ofﬁce. I don’t think they truly appreciate
your relationship with your client. I think they are task oriented and
less sensitive to the dynamics of a relationship and that includes
nurse to client, and nurse to physician, and the dynamics from
client to physician there. Only the nurse is sensitive to that. The
adjuster doesn’t always get a feel for that, what is actually going on.
And I think what adjusters don’t always know is how much ﬁnesse a
case manager needs in some situations to make things happen,
you know. So I think I feel like I have a harder time trying to
communicate what’s going on to the adjuster than I have to a
physician, to the client. I have, it seems to be a better ﬂow of
information here than sometimes with some adjusters. Some
adjusters just don’t understand. (Donna)

Another source of strain for new NCMs in relationships with adjusters was

an authority issue. The NCMs employed by WC insurance carriers believed that

83

the adjuster had the ﬁnal say in authorizing beneﬁt payments, and when and how
long the NCM was involved with the case. In essence, the NCMs felt that they
were expected to submit to the adjuster. Irene and Ann both shared their
frustration with what they perceived as a hierarchy in their ofﬁce that gave
adjusters the authority to accept or reject their recommendations on medical
claim decisions.

In the hospital you’re the boss generally. Usually it’s the nurse
who’s the [boss]. Aides may not like somebody but the nurse says,
'Well this is it. We’re going to do [this]." But in this role, the
adjuster owns the ﬁle and the case manager assists that person.
And most of them I get along ﬁne with. And most of them aren’t a
problem, but when you do get into that situation - [when] I feel
conﬁdent enough in my case management or my decision that I
think I’m right - then they’ll dispute the ﬁle or something just
because they don’t like the person... I ﬁnd that really stressful...
You’re working with people who have no idea what they’re doing.
You have people who are very, very good as adjusters. You have
unit managers that support you and you have unit managers who
think you’re a pain in the neck because they’d really rather do it this
way and be done with it. And then you jump in and say “Wait a
minute, wait a minute, this is a perfectly relevant thing going on
here and we’re not just going to close it.” (Irene)

As a nurse in the hospital, when there was a conﬂict with someone
else it was generally a lower discipline and you could say, “I am the
nurse you will not do this function.” Here we rely on each other
more - the nurse and the claims adjuster. I can’t do my job unless
she does hers or he does his. I can’t close out a case if they don’t
put in dates. And you tell them and you tell them and it doesn’t get
done. To me, that’s very frustrating. You get medical [records] on
someone and it’s like, “this needs to be done,” or “yes, this is a
relationship, this [complication] could have occurred from this
injury.” Well, they don’t want to see that. They only want to see the
main injury. And then there’s a problem further down the road
where we could have done something for the secondary
[complication] and got the guy back to work. (Ann)

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For Judy, an NCM working for a CM vendor, the issue of adjuster

relationships took on a different focus. She perceived a need to please the

adjuster in order to secure business. She seemed less conﬂicted over reluctance

or non-cooperation from adjusters than her fear of appearing incompetent and

therefore losing repeat business.

What was hard is there was this big fear of making adjusters think
you were competent right off the bat, so that they would refer you
more cases. Well you’re not competent right off the bat, so how to
accomplish that feat was just to me, you know, I didn’t know how to
pretend like I knew what I was doing. And so I would really limit my
conversations with adjusters so they wouldn’t get the hint that I
really didn’t know what I was doing - which I think was a mistake,
because then I couldn’t pull enough information on what maybe
they did want. And so there was always this ﬁne line of "Pretend
like you really are this, you know, great case manager," but then try
and ﬁgure out what that means because you don’t know.... My
mentor case manager projected this idea that l was supposed to
really be saving money. "Save money for them.” You know,
"Hound on the fact that you’re saving money for them in this area
and that area, yada yada, yada . Really, just let them know how
great you are and how good you’re going to get things done so
quickly, and yada yada yada. (Judy)

Interacting and developing working relationships with claim adjusters

proved to be a source of role strain for new NCMs who were accustomed to

being surrounded by medical personnel that shared similar experiences and

perspectives. Participants felt tentative in arguing their cases with adjusters

because of their lack of knowledge in the claim process and the regulations and

strategies that drove adjusters decisions. Some struggled with having their

judgement circumvented by adjusters and others were intimidated by the “new

world” of business that they had entered.

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Nurses working for HMOs did not interact regularly with adjusters. In fact
the interactions were quite infrequent and dealt mostly with getting or correcting
information for the ﬁle records. These NCMs interacted more with medical plan
directors, physicians employed by the HMO who are responsible for reviewing
claim requests for coverage that are outside of beneﬁt package. NCMs in this
situation plead a case for approval for extra services, goods, or interventions that
they feel are best thing for the member. Working with adjusters was not a source
of role strain for these NCMs.

New NCMs found that acclimating to a business culture and ﬁnancial
objectives contributed to role strain. Some participants did not anticipate the
discomfort they would feel in a payer setting. Nurses who were experienced in
the tasks of physical care and who had been entrenched in the norms and
perspectives of a healthcare provider setting, found this new business culture
somewhat confusing and intimidating. Among a number of environmental
differences, participants’ perceived signiﬁcant differences between support
structures, work objectives, and tools used in their previous roles as caregivers
and their current roles as case mangers.

Participants who work in claim ofﬁces with adjusters responded that
support for their role in terms of resources speciﬁc to their jobs and comradeship
is just not the same as in the hospitals or clinics where they had come from.
Ginger, for example detected some resentment from adjusters who were used to

handling claims without NCMs. It was difﬁcult for her, as a new NCM, to address

86

this issue with adjusters who didn’t seem to understand her role or appreciate her
involvement.

Well I think that at the hospital everybody even though they weren’t
nurses, it was more medically oriented. Whereas here...l feel that
we’ve had a good rapport [with adjusters] and we work together,
but there’s not the same trust maybe yet... I feel we should be
working together as a team and providing each other with
information. Sometimes I feel like I provide them with the
information when I get it but I don’t always get that in return. And
whether that’s because they’re not used to it... I don’t ever feel like
it’s pointedly not done on purpose, but I don’t get that feeling... I
mean they just don’t seem to be so excited about all the praise that
the nurses get this department in the ofﬁce. Sometimes I notice
that. (Ginger)

Ann detected a difference in the amount of collegial support she felt from
adjusters in the claim ofﬁce than she did from personnel she interacted with or
depended upon in the hospital.

Well, [in the hospital] you always had someone you could go to, be

it the director of the department, the nursing supervisor, another

physician, other nurses. Here you’re kind of left alone. We do

have our nursing team leader here who’s wonderful, but there is

that difference between us and the claim adjuster. And there can

be...a partition between us. They’re looking at something maybe

differently than we do and it’s hard sometimes to get them to

understand what we do. And that support isn’t always there. It’s

kind of sometimes them against us. (Ann)

Coming from clinical settings with a focus on providing patients with the
intensity and duration of care prescribed by their physicians, most participants
shared that cost containment remains an issue about which they feel some
conﬂict. Though they understood that the main objective of their role is to contain

healthcare costs, the patients’ welfare is still foremost in guiding their oversight

and authorization of payment for healthcare goods and services. This at times

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put them at odds with claim adjusters or medical plan directors whose main
concern is holding down healthcare expenditures.

Karen remarks that it has been challenging to focus on cost containment
in her role as a case manager with an HMO. As is the case presented by most
participants, her previous work environments in healthcare provider settings did
not require that she attend to that.

Financial concerns still kind of make me uncomfortable. I’m dealing

better with them and well you work for [an HMO] and that is an

issue. And if ﬁnances aren’t contained then people don’t have jobs.

And you know you really see that there are people that abuse the

system... I guess being raised in a hospital and in home care,

that’s not a concern I mean maybe it is now. It wasn’t when l was

doing bedside nursing. I mean if [patients] needed a dressing we

did a dressing. I mean if they needed medication they got it. If the

doctor ordered something he got it. (Karen)

Many participants recognize that the bottom line is paramount in the
business world. This inﬂuences philosophies about handling insurance claims,
which in turn impacts expectations of the case manager’s role in the process.
Some participants perceive this expectation as potentially confounding to their
role as patient advocate. Belinda explained that she feels a tension between her
role as patient advocate and the expectation that her inﬂuence on a case will
result in monetary savings for the WC insurance carrier she works for and
ultimately employers who pay premiums.

In this context your focus is not patient oriented. Your focus is

monetarily oriented. You’re more involved in following up from the

employer’s standpoint than you are of taking care of the patient.

And for me that’s a constant pull between the two - ﬁnding a place

where I’m happy with that I’m doing the right thing for the employer

who ultimately is paying for my services, but as a nurse making
sure that patient is getting the care that they need and require. And

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that was a hard place to come to. That took me a while to get
there. (Belinda)

Another source of role strain for nurses entering a business environment
is Ieaming to use the tools available and necessary to complete tasks associated
with their new role. Fran describes her adjustment to business-appropriate
communications and the need to collect and compile data and demonstrate
trends and outcomes.

The biggest transition from care giving to the business world it’s
Ieaming to do memos and e-mails and, you know, business-
appropriate. It truly is. That was the biggest thing...because you’re
going from, you know, staff nursing... If you take a staff nurse
who’s biggest concern is making sure the meds are passed and the
bed is made and the NS are hung to...a position where you really
need to produce a statistical report, it is a big transition. You need
to show outcome. You know, all these different case management
tools that we use are so different than the hospital stuff, it really is.
(Fran)

The use of personal computers (PCs) and all the electronic means
of communication such as email, voicemail, faxes, and cell phones as
necessary tools to complete tasks at work stations were also perceived as
a convention of the business culture that took some getting used to.

I didn’t have a lot of computer experience but I don’t think that’s all
it was. I wasn’t nervous about that because we used computers at
the hospital, but not to the extent that we have to input data here.
And of course, that was expected. I mean it’s telephonic
information. You have to document it. (Ginger)

I had some computer knowledge, you know. I mean I had taken a
class on my own so I knew what a computer [was]. I wasn’t a whiz.
I had a lot to learn. I still have a lot to Ieam. 'Cut and paste,’ I still
have not gotten that down. I’m working on it, but you know I’m a
very moving person. I don’t like to sit, and sitting just, you know.
Ok, I gotta get up and walk. I can’t do this, you know . I’m always
ﬁdgety, but in the ER we never sat down. (Ann)

89

Though Donna had experience with the business side of healthcare
in roles as nursing director of general practice and occupational health
clinics, she struggled with the technical aspects of setting up and
managing business from an ofﬁce in her home.

Because we work remotely we need to be connected to our

organization, to our group, to our supervisor. There [are] all these

surveys and expense reports and all this miscellaneous stuff that’s

much more difﬁcult to do.... in your home ofﬁce. Whereas if you

were in a building you could run over to so and so [and say], ”Hey

show me how you do this expense report.” Those things are

piling up for me. I don’t really have two hours to go through how to

do an expense report for this and that. So there [are] things that

are piling up because to get the assistance to go through that, even

though I’ve tried, ok it’s still like, send an e-mail off to an admin,

”Please tell me how to submit my phone bill from December. " [And

they reply], "That goes on an expense report." Give me details,

exact details. "It goes on an expense report." Ok, back to the pile

it goes. (Donna)

Coming from clinical settings where staff were medically oriented and
committed to providing patients with the intensity and duration of care prescribed
by their physicians, new NCMs found a certain amount of role strain associated
with entering a business environment. Interacting with a majority of non-medical
coworkers, attending to a business objective of cost containment, and the
incorporation of clerical tasks and new tools speciﬁc to the business environment
all contributed to the experience of role strain for new NCMs.

The forth theme that emerged from interview data and focus group
discussions with regard to sources of role strain are experiences and perceptions

associated with professional identity and self mage. While most participants view

CM as a legitimate area of practice within the nursing profession, some assign a

90

personal value to the case manager role as less important or less signiﬁcant to
their previous role as a caregiver. Ginger, for example refers to case
mangement as “another phase of nursing,” but does not believe a nursing
background is necessary to do the work she is doing.

I just don’t feel like a lot of what I do is nursing decisions. It seems
to me that anyone could be trained for what I do, [anyone] that
doesn’t have a medical background... I mean there are certainly
times when my nursing knowledge has an impact, but I think for the
most part it seems like it’s basically a lot of things that the claims
adjusters did before as far as authorizations, approvals,
procedures, what have you, following doctor’s visits. That could be
done by someone more trained to do it. (Ginger)

Belinda struggled with expanding her notion of nursing to include the role
of case manger.

It’s a different job and it’s not what you think nursing is going to be

and it’s not where you thought you would be as a nurse when you

graduated from nursing school. The last place I would have

expected would be sitting behind a computer at an insurance

company and still calling myself a nurse. And I do, and I am. So

it’s outside my perspective of what a nurse is and what a nurse

does. (Belinda)
Because of what she has experienced in her role as a case manger, and the type
of problems she has faced in interactions with some WC claimants, Belinda feels
a need to hold back on what she held as a characteristic nursing behavior, which
is empathizing with and unconditionally supporting the patients she deals with.
She also concedes, however that that she is building knowledge and skill that
she ﬁnds valuable.

You just can not do that here, because your function here is not to

be that person. They’re not paying you to be that person. The

doctor’s ofﬁce was, and the hospital was, and that’s what you did
when you were in nursing school. And what you really, really, really

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want to do is just be Florence [Nightingale]. But you have to [put]

that aside for other things here. And I don’t necessarily think that I

have lost anything because I have picked up in knowledge and

abilities and different aspects and outlooks that I would not have

even given another thought to before. (Belinda)

lrene’s difﬁculty is associated with the lower esteem she affords her
role as case manager in comparison with the esteem afforded to her in the
role of caregiver. Though she feels that she is becoming more skilled and
knowledgeable as a case manger, she is much more aligned with her
identity as a pediatric nurse.

I think when you tell people you are a case manager in an

insurance company they think you know it’s no big deal I don’t think

people have a lot of respect for case management... I think they

think you just run around and try to cut money you know I really do

and if you say you’re a pediatric nurse people go. “Oh wow! That’s

so good! Oh my little grand baby just fell down the stairs

yesterday”. . .. There’s deﬁnitely a difference for a [pediatric] nurse.

Yes, I can honestly say that I would have no doubt about. People

say what are you doing now. “ Oh.” You know it’s just not the

same. (Irene)

Though all participants reported that their professional identity is that of a
nurse, some aspects of the case manger role seem to be in conﬂict with the
unbiased and apolitical image they predominately hold of themselves as nurses.
For some, clinical competence and unconditional nurturing care is held in higher
esteem than the impact they feel they can make as case managers.

To summarize, characteristic sources of role strain for new NCMs
revolved around four themes, (a) time-task orientation, (b) interactions and

relationships, (0) business culture and objectives, and (d) professional identity

and self image. Participants shared their experiences of confronting the need to

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accommodate their assumptions and approaches in several areas of their work.
The process of this accommodation contributed to role strain, but also stimulated

professional growth and eventually contributed to job satisfaction.

Sources of Job Satisfaction

Despite experiences of role strain in the transition from caregiver to case
manager, participants reported sources of job satisfaction that they associate
with their role as case manger. These sources fall into ﬁve categories: (a)
facilitating recovery and impacting healthcare outcomes (b) opportunities to
expand knowledge and skill, (0) enhanced professional growth and conﬁdence,
(d) appreciation and respect from others, and (e) autonomy.

NCMs involved in WC cases ﬁnd satisfaction in facilitating the recovery
and return to work process for injured workers. This process can be long and
complicated. It involves getting to know the claimant, his or her treating
physician(s) and employer. For new NCMs it may involve research into an
unfamiliar medical specialty to learn about treatment protocols and available
resources. It involves determining claimants’ ability to cope and follow through
with the prescribed treatment plans. It can involve referring claimants to a more
appropriate medical specialist, coordinating treatment goals and plans among
multiple providers, providing patient education and encouragement, and
arranging for work accommodations with employers. It very often involves twists

and turns in the form of physical, emotional and interpersonal complications

93

along the way that the NCM must address and try to problem solve around in
order to realize the long-temi goal of recovery and return to work for the claimant.

Belinda explains that her satisfaction in facilitating recovery and return to
work is often preceded by situations that also cause her a considerable amount
of frustration. Being able to impact the outcome, however, provides her with a
sense of accomplishment and competence. She also ﬁnds that difﬁcult cases
provide opportunities for her to expand her knowledge of various medical
specialties and the WC claims process.

What I ﬁnd rewarding I sometimes have a problem with from other
aspects. When I have somebody who has been out there forever
on [work] restrictions, [and] you have IME [independent medical
examination] after IME saying there’s nothing wrong with this
person and they keep getting on and on and on, and you eventually
get them back to work at a job that you know they can do. You get
them out of their house, whether they’re happy with you or not.

You would’ve put a productive person back to work, be it at $5 an
hour or back at their own job. So I do like that feeling of
accomplishment when you get somebody released to work.... I
have one lady in particular that I’ve had open now for ...probably
going on 2 years this July. And I got her back to work a little over a
year ago. And she’s still whining and she’s still on restrictions but
she’s still going everyday. And we’re working right now to put her
back onto the ﬂoor. At this point she’s just doing telephones and
she’s had some problems, but we’re working on that. But she’s
working and otherwise she would have been sitting out there doing
nothing. And I don’t think that’s healthy for anybody. It gets to be a
behavior and so I do like getting them to go back to work. I love the
nursing part of it. I like the learning part of it, the ability to be
involved in more than one specialty, picking up bits and pieces of
information that will eventually be put together and we can make
what we think is a pretty clear idea of what’s going on with
somebody. (Belinda)

Cathy describes a sense of satisfaction she gets from producing outcomes

that meet the needs of all stakeholders involved in the claim process. Her

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understanding of the dynamics of multiple stakeholders in the claim process is
part of the expanded knowledge and skill she has realized in enacting her new
role as case manger.

I enjoy working with clients. I know that there are claimants who
may malinger, but I think that generally speaking most people want
to be well and I enjoy when I can look at someone impartially.
Maybe because I’m newer and not [assuming] that they’re trying to
take advantage of the system, at least not assume until I’m proved
othenrvise, you know. But when I can resolve a ﬁle in a way that I
feel good about this, that the claimant feels good about this
resolution, the employer feels good, and the adjuster feels good,
then I feel good. It feels good. (Cathy)

NCMs who are employed by HMOs ﬁnd satisfaction in their roles from
their capacity to help members gain the most beneﬁt from their health plan or ﬁnd
alternative sources for services or ﬁnancial support. They have the capacity to
identify members who are need of special services and to access them, to
inﬂuence coverage approval for extraordinary circumstances and to run
interference for members in need of immediate assistance.

Fran describes her main source of job satisfaction is in assisting members
to navigate through a complex healthcare system that often is over or under-
utilized by patients due to the confusion it fosters.

I truly like navigating someone through this hideous horrible

monstrosity called health care... This is the corniest of all. When

someone asked me why did you go into managed care and I said,

"You know why I went into managed care? I wanted to humanize

managed care." And I mean that with all my heart, I really did. It

didn’t always happen but I want to be able to hold someone’s hand

and help them through because it’s a damned maze you know it is.

I mean it’s a horrible maze. I don’t understand how people who are

physically or mentally compromised can make it through the

system. They don’t. They don’t make it through the system. lﬁnd
it very rewarding to be able to help someone through confusing

95

[situations] in health care (Fran)

Evelyn ﬁnds the personal thanks she gets from families of the pediatric
patient population she serves to be quite rewarding. Her capacity as a case
manager to inﬂuence coverage decisions, and get questions answered for
members has also enhanced her conﬁdence.

What I ﬁnd satisfying about it is the thanks I get from the families
when I put them in touch with other things. Or when I explain to
them what their actual contract covers and that I went to the doctor
and we discussed it and yes he approved it. So it’s just the
satisfaction I get from them when they say "Thank you. Thank you
for helping me. I’m so glad I have you here to help me. I would
have never known, you know. Nobody answers questions” or "I
didn’t’ know how to navigate the system to get these answers."
(Evelyn)

In addition to facilitating recovery, and being appreciated by claimants who
were helped, many participants ﬁnd that their roles as case managers affords
them more respect for their knowledge and judgment than they experienced in
care giving roles. Hannah explained how the patients, physicians and adjusters
respect the value of her involvement in the claim process, and that adds to her
job satisfaction.

I think the patient sees you as helping them but they also realize
that there’s an adjuster and insurance company that oversees what
can be done... You’re giving the adjuster information. The patient
understands that you can help them explain their situation and get
approval for certain for certain things. [With] physicians, I see a lot
more, even more respect for nurses [in CM than in caregiver
roles]... They understand that...workers comp is paying their bills
so they try to work with the nurse and you know, try to get a plan
that is agreeable to the patient and to me. They always, you know,
they deal with the patient. And I always sit back in the beginning
because the physician and patient I feel need to establish a rapport.
And then a lot of times at the end of the visit I will talk to the
physician...or they will ask me, “Do you need anything else?” So I

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feel for the most part you get a lot of respect from the physicians...
I think in some ways you get more respect...for your knowledge,
especially with an adjuster who doesn’t really understand the
medical aspect. (Hannah)

Participants identiﬁed autonomy as a source of job satisfaction. They
explained that the case manager role allows them autonomy in working ﬂexible
schedules, in prioritizing and organizing tasks associated with their caseloads
and in addressing their own Ieaming needs. Irene demonstrates a common
sentiment among participants.

I like the hours, the ﬂex-time. You know, you can work kind of when

you want, anything you want...l guess to a point [CM] gives you a

little more, what’s the word? Autonomy. You pretty much set it up

and this is how you organize it. You set it up and plan it through

and hope that it goes. You’re deﬁnitely on your own more. (Irene)

Though there are speciﬁc policies and procedures that NCMs are required
to comply with, they feel relatively free from constraints in how they go about the
business of managing cases, compared to the rigid structure of hospital or clinic
routines. Donna ﬁnds satisfaction with the autonomy allowed in creating a work
schedule that accommodated her family obligations. She also ﬁnds the
opportunity this autonomy provides for professional growth and development to
be satisfying.

[CM] works. It works for my family... In the job that l had...l had to

work from 7:30 to 4. I couldn’t leave to do my taxes. I couldn’t leave

early to pick up my son if he got sick... And you know you had a

doctor that watched every move you made. So ...even though

you’re a professional there, you couldn’t really develop it much

because you had limitations of what your job was. You give

immunizations for travelers, and ﬂu shots, and little injuries for

people who pass out at the [work site]. You know there’s not a

whole lot going on [there] professionally... [In my current job]...l
can adjust my workdays according to what my family situation is at

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the time... It’s a job that I can develop. I can develop this job to

whatever I see it as, my vision of the way I want to be as a case

manager... There’s the autonomy that I can be any kind of case
manager that I want and, as I would like to be. (Donna)

While the autonomy associated with the role of case mangager, offers the
convenience of ﬂexible schedules, the freedom to exercise personal preferences
in work organization, and the challenge to develop professionally, as mentioned
previously, it is also a source of role strain for new NCMs. Interview and focus
group data suggest that autonomy can become problematic for nurses
transitioning from caregiver roles who lack familiarity with effective practice
strategies. This will be discussed in more depth in the next section, “Learning
Experiences.”

Job satisfaction comes from a number of sources for nurses who have
made the transition form caregiver to case manager. Participants identiﬁed
sources of job satisfaction that generally ﬁt into ﬁve categories: (a) facilitating
recovery and impacting health outcomes, (b) opportunities to expand knowledge
and skill, (c) enhanced professional growth and conﬁdence, (d) appreciation and
respect from others, and (e) autonomy. Participants, however, have identiﬁed

autonomy, as contributing to role strain as well, in terms of limited direction for

Ieaming effective CM strategies.

Characteristic Learning Experiences
Nurses entering the ﬁeld of case management require instruction,

guidance and socialization in order to effectively accommodate existing

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knowledge and skill to a new context and gain professional judgment and
conﬁdence in fulﬁlling the responsibilities of a new role. Many participants
explain that, as competent as they felt they were in their respective clinical roles,
the experience of moving into this new work environment is challenging and
involves more than simply utilizing their clinical knowledge.

Hired for their knowledge of healthcare and their abilities to understand
and relate to physicians and patients, most participants lacked knowledge or
even awareness about issues in managed care and third party payment systems.
They struggle with new concepts, new types of working relationships and new
tools. For many, this learning curve is steep. However, through a combination of
formal orientation and training programs, on the job experience, guidance and
support from colleagues and self—directed learning strategies they manage to
function as case managers.

Learning experiences characteristically associated with participants’
transitions into case management include: (a) attending employer
sponsored orientation and in-service programs, (b) reviewing policy and
procedure manuals, (c) shadowing coworkers, (d) reviewing ﬁles or
discussing cases with supervisors, (e) attending vendor and provider
presentations, (f) networking with coworkers and professional colleagues,
and (g) Ieaming from successes and errors on the job. Not all participants
had access to or participated in all Ieaming experiences listed here.

Rather, each had a relative variation consisting of one or more of these

experiences. These variations were related to the time and place of

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employment of each respective participant, and, I suspect, subject to the
accuracy of participants’ recollections.

For example, Ann, Belinda, Ginger and Irene are all employed by
the same WC carrier, and work in the same branch ofﬁce. They were
hired within the past three years, but they did not have initial Ieaming
experiences at the same time. Their descriptions and impressions of their
initial learning experiences reﬂect variations in orientation agendas, as
well as, perhaps, variations in what each attended to and recalled.

Ann reported her initial Ieaming experience as a loosely structured
orientation that provided her with the opportunity to observe a case
manger in action and then gradually take on the responsibilities of her own
case load.

I had two weeks orientation with another nurse case manager.... I

sat with her for the ﬁrst few days, watched her, read over the

manual, and then slowly was put into the position by a case to work

on, with her coming and checking my work and making sure that l
was where I should be, and doing what I should be doing. (Ann)

Belinda recalled that her initial training involved a “formal training program”
that her supervisor had designed and presented to her and another new hire. It
consisted of reviewing policy and procedure manuals and instruction in speciﬁc
tasks and duties such as claims data entry, documentation, steps in the case
mangement process, and timeframe expectations.

Case management was a formal training program that my

supervisor here had put together to get uniformity in what people

were doing. And I found it very easy to follow. We also had a

computer program that prompts you to do certain things, and that
was a very good resource. But I would say that the training that I

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got here through the program that was put together was very
good... We started out with our books and we were given our
books to look at and to go home and read. Basically there were
two of us that were starting at the same time... I was available
before the other person was, and they didn’t want to do it a week
apart. So they said, ”Just take the books home. Look at them and
we’ll have you both come back on this day.” And we went over the
books. We went over the screens on the computer that we use,
screen for screen. She talked about the codes that needed to be
used, the way that notes should be written, the phone calls that we
were expected to make, when we were expected to make them, the
decisions that we would be asked to make, and what we were
expected to do for follow up. (Belinda)

She also indicated that six months later she was sent to an “ofﬁcial” program for
a week on the entire claims process that conﬁrmed her understanding, if not
introduced her to, how case management ﬁt into the picture.

Ginger described her orientation process as an “in-service” program,
review of manuals, computer instructions, and explanations of what was
expected. She felt, however “left alone” to Ieam how to apply the information on
the job.

They provided an in-service when I ﬁrst started. Basically I felt I
was left alone a lot to just learn on my own. I mean they provided
the manuals and what have you, but I felt I learned more doing the
hands on... [I was] on the computer and following through on what
was presented to me in the manuals and during orientation. Until I
actually got my own case load and had to deal with what was
expected, I think that’s when I ﬁnally started Ieaming and had more
questions... What I’m saying is when I ﬁrst started...it was a lot to
grasp.... but it was just more or less, you know, this is presented to
you, and this is what you’re expected to do. And then everyday
coming in, and you know, read these procedures and read that
procedure. Well until I have to authorize the surgery, I'm not going
to remember all these steps, you know, ten steps to do or what
have you, and that’s the kind of thing... which protocols are
approved...what the time element is in approving a surgery from
when you get the call, to get the approval for physical therapy or
certain procedures that are not going to be covered under work

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comp. (Ginger)

Irene recalls a one-week program on “the case management experience.”

She was disappointed because the program seemed more appropriate for

adjusters than NCMs. Coming from a background in pediatrics, and facing the

task of managing WC injury cases, she was hoping to Ieam more about

advanced medical issues associated with those types of injuries, treatment

protocols and reputable healthcare specialist that she felt would have been more

relevant to her Ieaming needs.

They did send us for some in-service classes. . .for a week [on] the
case management experience. The problem I had with a lot of
them was that it was not as medical as I would have liked it....
[They taught us] mostly when, maybe, to deny a case, when was
surgery, when was it not appropriate, how to kind of get an idea -
which I still have a problem with - suspecting fraud. That was a big
part of it. That’s why some of the training I didn’t think was as
medical. It was more, I thought, adjuster oriented, because we
don’t do that anyway. We don’t deny. We don’t. But it gave you
background into what you are supposed to be doing, and what
might give you a hint, because we do often make a better
relationship with the workers than the adjusters. And sometimes
we pick up things that you think, "Oh, something is not right here,"
you know. We learned simple things like parts of the body and
muscles and things like that. (Irene)

Donna, who works for another WC carrier, described a more intense initial

training experience and describes sessions that speciﬁcally addressed CM skills

and those that addressed company procedures. Like Ginger, she found that too

much introductory information without the ability to apply it soon after created

some confusion.

They have a training program ...a two-week training program
now...lt’s very intense... There is so much information that they
provide you... Some of it is generic case management, this is how

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you conduct your initial assessment. And they showed us videos
on how to meet with the client for the ﬁrst time, how to meet with
the physician for the ﬁrst time...how to obtain the information you
need. Those to me, that’s generic. That’s not company speciﬁc...
That’s teaching you the skills. What it mostly involved, though, was
this is the [company] way. These are the [company’s] forms. This
is your laptop and this is where you put the information on these
forms. So most of it was [company procedures]...and the
expectations you’ll have this form done in 48 hours, this one done
in 7 days, etc. And that part was intense because you’re trying to
pull it all together to make some sense and you’re not if you’ve
never done a 100% case management it seems like a lot of work
and a lot of forms and a lot of things that don’t mean anything
...until you start doing these things then you understand what they
are. (Donna)

Judy, Hannah and Cathy, who work for CM vendors concurred that there
was little in the way of a formal introduction to CM for them. They all practice on-
site CM, which puts them out of the ofﬁce and into the ﬁeld on their own. The
element of ﬁeldwork constrained opportunities for impromptu Ieaming from
colleagues. When Judy was asked about the learning resources that were
initially available for her to learn CM she replied:

They are not as developed. l have found [that] there’s so much
diverse ways of understanding what the case manger’s role is, and
there [are] different personalities. In these past 15 months what
I’ve found is a real hard time getting support from the employer that
l was at. They buddied [me] up with a case manager who was very
successful in her role, but she had a very different personality than I
do and I didn’t like calling on her.... They had another woman that
was in the ofﬁce... and she was wonderful. Having someone there
to answer those questions was very helpful... but then after six
months she started going out in the ﬁeld, so she was no longer
available to me. What was hard is so many of [your coworkers]
say, "Oh well you know feel free to call me." Well, you know
they’re gone during the day. That’s when I want to call them. I
don’t want to call them at 7 o’clock at night when they get home. I
don’t want to deal with work at that time of day either, so when she
was out of the ofﬁce, that was a real disappointment for me, that
there was nobody then... They had a couple of meetings in [these]

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hai

15 months, and I found them to be extremely irrelevant and very
poorly presented, not helpful for someone at my level. They were
geared more towards people that maybe had been in case
management, talking about maybe speciﬁc guidelines in a workers
comp thing, while I’m trying to understand the broad basic
guidelines. Don’t go into one, you know, obscure element of these
things and hound on that when I don’t know even understand the
bigger picture. So that was really frustrating, very frustrating.
(Judy)

Hannah and Cathy reported that their employer provided no formal
program orientating them to the role of case manger. They had some policy and
procedure manuals to read, shadowed another NCM for a few ﬁeld visits and
discussed issues on a case-by-case basis with their supervisor.

It wasn’t really a formal training. It was more you came in they
gave you cases and you just asked questions. And that could have
been partly my personality because I think I picked it up pretty
quick, as my boss said. So it was more a matter of working the
cases and constantly going to them to ask questions. I did go
there. I took over for another nurse that was leaving, so I went out
with her I think it was two or three visits and then...you know, I just
then took a case load and started working it.... There was more
paperwork, you know, things to read. There [were] a lot of things to
read. . .. like policies, and it wasn’t actually a book on case
management - just different processes like workers comp process.
(Hannah)

We did some reading, but it was most Ieaming from doing, which I
ﬁnd works best. Like I said, we went to appointments with other
nurses to see how they functioned in the appointment and then you
learned from doing. And you met with [the supervisor] to talk about
your ﬁles and how you were progressing with your ﬁles. And if you
had any questions with your ﬁles you were encouraged to speak
with some of the more experienced case managers here with any
questions. (Cathy)

Fran, Karen, and Evelyn, all employees of HMOs, echoed a report of

having no formal training in case management, and basically Ieaming to function

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by doing and asking questions. Fran described her Ieaming experience as "on
the job training," and shared that "probably three months of it is just getting
acclimated to that different environment, to the different expectations.” Karen,
who works with Fran, responded to a question about what resources were
available for her to learn CM by gesturing a zero with her thumb and index ﬁnger.
She further explained ” I really still feel like I’m ﬂoating around. I feel like I’ve
gotten more in the past 2 years just by [networking with] other case managers."

Because Evelyn was hired into a position that had not been occupied
before, aspects of her role as a pediatric case manager were not yet established.
She had considerable leeway to develop the role, but she needed a place to
start, some example from which to shape her role.

Actually looking at the job description, it wasn’t that clear. It was so

general. When I came here there were two other case mangers

who... specialized in a particular area. I specialize in pediatrics.

There was one who specialized in oncology and one who

specialized in obstetrics. So when I came here, I was put with

those two to see what they did and then that’s what I was told that I

would do... You know we work in cubicles so it wasn’t really

following them around, I would sit with them at their desk and listen

to the conversations they would have with members and doctor’s

ofﬁces and that’s how I [learned case management]. (Evelyn)

Though some participants indicated that formal training programs lasted
only one or two weeks, all acknowledged that learning occurred on a daily basis
in the course of enacting their role and interacting with others. Utilizing other
case managers as resources was by far the most common way that participants

found answers to their questions. However, participants working in the ﬁeld

voiced frustration with not being able to access their "resources" when needed,

105

as indicated previously by Judy. Donna related that she is reluctant to call her
designated mentor for help for fear of taking up time her mentor needs to handle
her own cases.

[A coworker] has been assigned to me as a mentor. I told my

supervisor this and I told [my mentor] this. " [Mentor], you’re a case

manager. You have to bill for hours. There’s no way I’m going to

bother you with any of my questions.” So I go to my supervisor. I

can pick up the phone and call [my mentor] and I’ve met [her] for

lunch, you know. And we’ll chat informally about some of the

cases, the most interesting cases, good or bad. But I stay away

from calling [my mentor]. She’s a good resource. She’s very

experienced. But this billing situation thing, it’s like there’s no

way... I’m not going to call her. I’m not. I’ll call my supervisor

because she doesn’t have to bill for her time, you know. (Donna)

Networking with other NCMs, as previously referred to by Karen, provided
participants with a signiﬁcant amount of informal learning, and contributed to how
they understand their role, the tools they used in executing their job
responsibilities and the healthcare providers and services they recommended to
others. This networking occurred mostly among coworkers, though some
participants found local professional meetings or continuing educations programs
to be venues for networking with NCMs from other organizations.

Irene, like her coworkers, takes advantage of local professional
association meetings, presentations offered by healthcare providers and
vendors, and the group of NCMs that work in her ofﬁce to network. She ﬁnds
that networking helps her to get answers to speciﬁc case-related questions and
to ﬁll in the information gaps she identiﬁes in the course of her work.

I go to every little opportunity [to network], to all these little

[professional CM] meetings. | go to everything... Why [I] go to all
that stuff, well because I really need it... Not being on top of things

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is very stressful for me, being the dummy, being the new guy. I

hated that... I actually formed a group because it was a problem

for me to know some of the [healthcare resources], where to send

[claimants], what rehabs were good, where they are. l formed a

group [of my coworkers]. We all sat together one night till about 9

o’clock and we went through all the card indexes and reviewed

[providers we had used for referrals]. (Irene)

All participants share that they are free and even encouraged by
supervisors to take advantage of Ieaming opportunities available within and
outside the company. They are not, however, necessarily guided or directed in
the availability or selection of these opportunities. This facet of the autonomy
they otherwise enjoyed about the role contributes to an uneasy vagueness about
whether or not they actually “know” what case managers should “know,” and how

to go about ﬁnding out.

Perceived Effectiveness of Learning Experiences

Participants see formal instruction, i.e. classes, manuals, videos, and
computer programs on speciﬁc company policies, procedures and tasks
associated with CM as necessary. These new NCMs came into the role without
much prior knowledge, and needed information. Formal orientation and training
programs that provide new hires with information about role expectations, tools
for the job, and resources for later reference are favorably received. Those who
did not receive such instruction suggest that it should be provided for new NCMs.
Hannah, who did not receive formal instruction, remarks:

Things weren’t as clear to me in the beginning because it was more

of 3 “Here is your case. Just go out and stumble and ask a lot of
questions.” I think I would probably do a little bit more bookwork in

107

the beginning, or explaining things a little bit in the beginning. One
thing that [my supervisor] also did is had you pull charts and read
charts. That was very helpful. Just maybe a little more formal
education in the beginning rather than that complete “Here’s your
case load,” you know. “Go ahead and do it and let me know if you
have any questions” (Hannah)

While training sessions, policy and procedure manuals, and computer

tutorials are viewed as necessary, many participants share that they are not

sufﬁcient. New NCMs prefer to have opportunities to apply some of what they

are Ieaming interspersed with those formal methods of instruction. Ginger,

whose employer provided a formal program initially, found the material a bit too

much to absorb, and needed a balance between new information and the

opportunity to put it to use.

Starting in a job like this and coming out of the hospital that was the
ﬁrst thing that kind of hit me...it was such dry material. All of a
sudden, it’s just all this manual thrown at me. Like I’m supposed to
remember it all... I’m a hands on person. I guess...the clinical was
always easier for me to be able to correlate what I learned in the
books you know... I always think it’s a little bit easier when you
incorporate some hands on or some book learning together. So I
think that in the beginning, it may have started out a little dry
because of the fact that everything was kind of like presented in
book form before being able to apply it. I think that you should be
allowed [to apply it]. (Ginger)

Shadowing others is seen as an effective Ieaming as well as

socialization experience for new NCMs. Several participants followed

experienced NCMs in the course of their duties, which assisted the new

hires to formulate questions and observe procedures in context. It also

gave them an idea what to anticipate and how they might need to prepare

for their own experiences on the job.

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lrene’s orientation to the job did not include shadowing. Though she
practices telephonic CM, and her colleagues are just a cubicle away, she feels
that their expertise was not as accessible to her as she would have preferred in
the beginning. A dedicated period of shadowing, she speculates, would have
been an effective way to learn not only tasks, but also to gain some insight into
the type of decision-making expected of a case manager.

I think if I could have gone through ﬁles with someone and watched
them - and I realize that this is not always a practical thing - but if I
could have watched somebody do their ﬁles for two weeks, and
have them explain, you know, “Ok I’ve decided that I’m going to do
this and that,” that deﬁnitely would have been more help to me... If
I could have listened to her make that call instead of calling
myself... Just saying you have 24 hours to make this contact, oh
boy, you know, not that some things weren’t written down, but ...I
would have preferred to hear it, and have listened to someone
actually go through a ﬁle explaining it... know that that’s not
always practical. But I know it’s the biggest complaint of all of
those who have come after me. They say you just kind of wing it
and then they tell you if you’re off.

All participants express the value of having accessible resource persons
available to provide on-going feedback and answer questions. Cathy comments
about the signiﬁcance of coworkers and supervisors in her development.

I’ve learned from the [NCMs] here. When a situation arises that is

complicated, maybe I’ll talk to the [NCMs] here, ask them their

experiences, things like that. Or just listening to their

conversations, or being part of their conversations regarding their

cases of things that they’ve experienced, and things that they’ve

found challenging, and how to handle it. (Cathy)

Having resources available to discuss CM problems and strategies is

important, but also having resources provide validation of the meaning new

NCMs ascribe to experiences is also valued. Participants share that refection

109

and discussion about their performance in the context of speciﬁc case
experiences helps to shape their professional judgment, and serves to sharpen
their focus in self-directed Ieaming efforts.

Because CM involves collaboration with a number of stakeholders
associated with their assigned cases, NCMs need to learn about the roles and
perspectives of those stakeholders. Of signiﬁcance to new NCMs are not only,
for example, what an adjuster or a medical plan director does, but also the extent
of a case manager's inﬂuence in relationships with them, what they expect from
NCMs, and what NCMs can expect from them. Learning and socialization
experiences that address these types of things early on would have helped Judy.
She speculates that if she could go back and start again, she would attend to
this.

I would try to ﬁnd out from these adjusters, all this, you know pearly

wisdom that they have. You know, what are their expectations and

are their guidelines? I think they’re kind of very important in this

whole [thing], what they expect a case manager to do. I don’t have

any problem understanding nursing, but I do have a problem

understanding the insurance piece... I don’t think you could really

capture every problem...but if you knew what was appropriate and
inappropriate for a case manager to do, you know, what are red

ﬂags to adjusters, I think that would be very helpful. (Judy)

Participants also identify speciﬁc in-service or continuing professional
education topics that they feel would ﬁll in the information gaps in their
knowledge base. In addition to updates about various medical diagnoses and

treatments, topics such as cost beneﬁt analysis, legal issues in healthcare,

workers’ compensation and automobile insurance coverage, and community

110

resources to augment covered beneﬁts are suggested. These topics represent
areas in which they feel least prepared.

As previously outlined, participants described seven characteristic learning
experiences associated with their transitions from caregivers to case managers.
These experiences include (a) attending employer sponsored orientation and in-
service programs, (b) reviewing policy and procedure manuals, (c) shadowing
coworkers, (d) reviewing ﬁles or discussing cases with supervisors, (e) attending
vendor and provider presentations, (f) networking with coworkers and
professional colleagues, and (9) learning from experience on the job. Though a
number of participants had formal or structured training opportunities, many
remarked that the initial training they received failed to give them a
comprehensive understanding of the CM role or what difﬁculties they might
experience in the transition. Many relied on asking questions of their coworkers
and on trial and error. Some sought out opportunities for networking with other
NCMs

Learning and socialization experiences perceived as effective by new
NCMs include a combination of hearing, seeing, and doing. The right balance of
formal training sessions with opportunities to observe others, and time to try out
new tasks and approaches on their own with support, guidance, and validation
from those with more expertise enabled new NCMs to expand their knowledge
and skill and gain conﬁdence in their professional judgment.

In summary, this section presented data that addressed the research

question: Are there characteristic motivations, expectations, sources of role strain

111

and job satisfaction and learning experiences associated with nurses role
transitions from caregiver to case manager? Overall, data from personal
interviews and focus group discussions corroborate on a number of characteristic
aspects of this transition experience for participants in this study.

A common motivation to enter the ﬁeld of CM is a desire to ﬁnd an
employment option that eliminates the need to deal with undesirable work
conditions. This motivation feeds stronger expectations of relief than
expectations of professional challenge, growth or development from new NCMs.
In other words, nurses move into case manager roles with little to no knowledge
of the scope of CM responsibilities, the problems or struggles they might face in
role transition, or the opportunities to grow professionally as a case manager.

Sources of role strain experienced by participants characteristically cluster
around four tensions: (a) time-task orientation, (b) interactions and relationships,
(c) business culture and objectives, and (c) professional identity and self-image.
These tensions reﬂect the types of accommodations participants struggle with in
their transition from caregiver to case manger.

Sources of job satisfaction experienced by participants cluster around ﬁve
areas: (a) facilitating recovery and impacting health outcomes, (b) opportunities
to expand knowledge and skill (c) professional growth and enhanced conﬁdence
(d) appreciation and respect from others and (e) autonomy. These areas
represent opportunities associated with the case manger role that participants

have come to realize are both personally and professionally rewarding.

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Learning experiences associated with this transition are characterized by
limited formal training programs initially, on-going informal and self-directed
learning from actually managing cases. Though opportunities for learning are
viewed as a source of job satisfaction for many participants, the formal learning
resources that they perceive as available and relevant to novice case managers
are sparse. Networking with other case mangers is viewed as extremely helpful.

Despite a number of characteristic aspects of the role transition from
caregiver to case manager, data collected also demonstrate some divergent
experiences of this transition. Some of those differences most likely can be
attributed to personality traits, which are not explored in this study. Some
differences, however appear to be associated with past and present practice
contexts. The next section will show how data from interviews and focus group
discussions demonstrate contextual inﬂuences on the role transition from

caregiver to case manager.

Contextual Elements that Inﬂuence Nurses’ Experience of Transition

The second research question addressed here is: What elements of
contexts associated with past and present roles are inﬂuential in this transition?
This section will demonstrate elements of contexts that participants were
exposed to as caregivers and those that they are encountering as case
managers that either contribute to or moderate role strain. The inﬂuence of these

elements on nurses may account for experiential differences in this transition.

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Contextual Elements Of Past Roles That Contribute To Role Strain

Contextual elements of past roles that seem to contribute to role strain for
participants include: (a) physical task requirements, (b) focus on immediate
healthcare needs, (0) limited decision making responsibility or opportunity, and
(d) specialization. The extent to which these elements of past role contexts were
present appeared to inﬂuence the amount of role strain experienced by nurses in
this transition.

physical task requirements are signiﬁcant in the role of caregiver. Though
there are other responsibilities and expectations coinciding with that role, most
participants agree that providing physical care, or accomplishing physical tasks
was a major expectation in their previous roles as caregivers. In contrast,
participants shared that the major activities in their current role as case
managers— communication, assessment, planning, coordinating, monitoring and
evaluating -- are all done to effect the achievement of longer-term objectives.
This required a considerable accommodation for nurses who come into CM
directly from care giving roles where accomplishment of physical tasks is the
primary method of fulﬁlling role expectations.

All participants had some experience in care giving contexts where their
role involved mostly physical tasks. The hospital setting was a context where
this orientation was predominant. Judy’s experience was typical of other
responses describing this element in a hospital setting.

[In the hospital] you’re more a worker bee. That’s how it felt, like I

was just this worker bee completing tasks, tasks, tasks. No, it
didn’t really allow a lot for the art of nursing, on the ﬂoor that l was

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on. As far as the holistic type care, you weren’t able to really take a

whole picture and, you know, see what was going on. You were

more, you know, putting out ﬁres. Hang that IV, you know. Do this

[admission], and go change that bed, and you know.

However, Judy and a majority of other participants were exposed to care
giving contexts subsequent to their early experience in hospital settings. For
some, these contexts offered opportunities to adjust a physical task orientation to
a more mental task, or management orientation, which served to moderate role
strain for them in the transition to case management. For Donna and Evelyn, this
was achieved to a signiﬁcant extent with work experience as supervisors in clinic
settings. For Irene and Belinda, this was achieved to a lesser extent with work
experience in telephone triage for the pediatric clinics where they were previously
employed.

In care QIVIHQ 0003th there is a focus on meeting immediate healthcare
needs- Participants shared that in these contexts they were often limited in
awareness and concern to the episode of illness or injury at hand, and not
required to follow or facilitate patients’ recovery beyond the acute stage. As new
case managers, they have to adjust that focus to extend beyond the acute phase
and attend to the recovery and rehabilitation phase as well as deal with chronic
conditions. As NCMs they also need to include the interests of stakeholders in
the process other than the patient.

Nurses who had worked in out-patient clinics and home care settings

explained that these contexts broadened their awareness and understanding of

the recovery process as well as the impact of other stakeholders in the process.

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This was helpful in their transition to CM. For example, Belinda explained that
her clinic experience helped her to expand her focus from meeting the immediate
health care needs of patients in one episode of illness to building relationships
and arranging for things happen from a distance, over time.

They had what they called the nurse line there, and I really enjoyed
that job. That was basically talking to patients, following up with
new babies, answering questions on sick children. You name it,
they called us and asked us what was going on. We did some, I
hate to use the word diagnosing but patients would call and say,
"You know my kid is this, this, and this." And we’d say, 'Well, you
know it sounds like he could probably stay home another day,” or
”It sounds like strept throat. You better come in.” And so a lot of
what I do here [in my current role] is similar, although in many
respects it’s different. But we were doing what I would say some
case management before I came here, because we were given a
lot of leeway to make decisions. We contacted doctors, followed
up on necessary treatments and x-rays and hospitalizations, things
like that. All that was done from the phone... And the [key
difference] for me was getting to know my patients and making a
difference and being a part of the ongoing saga. And that doesn’t
happen for you in a hospital. It’s right here, right now, we’re
discharged, we're out of here, and we’ll maybe never see you
again.

Donna, who currently does on -site CM for a WC carrier, found that her
experience in health clinics at industrial plants gave her an appreciation for the
interests of other stakeholders in the course of injury and recovery of workers
who are injured on the job. This context expanded her awareness to include the
perspective of employers and what is involved with returning the injured party
back to his or her job.

[My occupational health background was] most helpful. And this is

my perspective in that because I’m so employer oriented, I ﬁnd that

part easy. When I go out as a case manager into these companies

and meet with employers and meet with HR people and walk with
the supervisor through an environment. I’m loving it... And I’m

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very comfortable with looking at a job, asking questions, and kind of

assessing situations. I know terminology [that] some nurses might

not. I know pallets and slip-sheets and duct plates and you know, I

know those kinds of things, what are pallets, what that means.

Where some nurses don’t really understand that and it might be

more intimidating to go into an environment that’s non-medical. I

love it.

Nurses in some care giving contexts have limited decision-making
responsibility or opportunity for suggesting or determining treatment options for
patients. They are charged with following physicians' orders for diagnostic and
monitoring procedures, and for administration of treatments and medication.
Participants noted that coming from such controlled and structured care giving
contexts made it difﬁcult for them to transition into a CM context where they are
expected to weigh the merit of prescribed treatment options and/or conﬁdently
argue their point of view with physicians.

Speciﬁcally, participants with hospital experience other than emergency or
critical care units commented on how that context offered limited decision-making
opportunities, or autonomy. This was true of some clinic experiences where
participants were charged principally with assisting physicians in setting up
examining rooms, taking vital signs and collecting specimens.

Nurses with home care experience, however felt that this context provided
autonomy, which helped them develop self-reliance and ultimately honed
decision-making skills. Hannah, Karen, Judy and Cathy all had some home care

experience. With the exception of Cathy, they indicated that the autonomy and

personal responsibility for a caseload of patients that extended beyond the

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hospital served to moderate role strain in their transition to case management.
Hannah's remarks are consistent with Karen’s and Judy’s responses.

The transition from a hospital to home care is difﬁcult because
you’ve got to be very independent you’ve got to make decisions on
your feet you don’t have people around you. That took me a while,
I think. I was younger at the time, didn’t have a lot of experience.
But by the end of my experience I think I was very good at it. And
you Ieam to be very independent, make decisions, know when to
call physicians. And you manage a caseload. I mean this one
person and all their problems is up to you, how often you see them,
that type of thing. (Hannah)

It was a hard adjustment to go from a hospital where you had
another shift behind you to where you were the last person in there
and you may be the next person in there In two days a week a
month or the next 8 hours, you know depending on what the case
was... [In the hospital] you were in the safe conﬁnes of the four
walls environmentally and you had another shift behind you and
you had educators and you had other people managers and when
you do home care, you are mainly it out there.... leaving the
hospital scene, it was such a four walls enclosed safe situation.
You learn so much more about how people function on their own
when you’re doing home care out in the community. (Karen)

The transition [to CM] was difﬁcult in trying to interpret [Automobile

Insurance] and WC guidelines. That part was difﬁcult. But one part

that was very similar was, you know, assessing the people,

interviewing people, developing a plan, setting goals. That was

similar. (Judy)

Cathy shared that her role as a visiting nurse in home care was more task
oriented. She only made visits to check on patients who required electronic
monitors or feeding tubes. Though she felt some autonomy in this role, it was
not signiﬁcant in developing her decisions-making skills.

Care giving contexts are often associated with speciﬁc settings and

medical specialties, such as hospital units or clinics that deal exclusively with

orthopedics, pediatrics, oncology. etc. This type of specialization. though

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enabling professionals to acquire sophisticated knowledge and skill in speciﬁc
areas of healthcare, also limits their awareness of the broader healthcare
delivery system and the interplay of variables within and without that system.
Participants with specialized expertise reported strain associated with learning to
deal with a different patient population and with gaining conﬁdence in their
interactions with a variety of stakeholders (physicians, adjusters, employers, etc.)
in the claim process. Participants with more generalized or varied experiences
as caregivers found this to be helpful in their interactions and problem solving
strategies as case mangers.

Belinda and Irene provide a good example of how specialization
contributed to their struggle in the transition to CM. The majority of Belinda's and
Irene’s work experience was in pediatric clinics previous to accepting positions as
WC case managers. The element of specialization in their past work context
created role strain for Belinda and Irene because of the signiﬁcant change in
clientele they deal with as WC case managers. They are now dealing with an
adult population, a variety of medical specialties with which they had no
interaction in their previous role, and return to work issues, for which they had no
frame of reference. In contrast, Cathy and Hannah had exposure and
experience in a variety of medical specialties and settings, which they believe
eased the transition in dealing with patients and and helping them navigate their
way through the healthcare system.

Evelyn, is an exception, however. Her experience and expertise is in

pediatric nursing exclusively, but she ﬁnds that to be a solid foundation for her in

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her role as a pediatric case manager for an HMO. She has maintained
essentially the same type of clientele, and understands a variety of healthcare
settings that offer pediatric healthcare services. There are more similarities
between past and present contexts for Evelyn, so this creates less strain for her
than for other participants whose previous ﬁeld of specialization is quite different
than what they encounter in their current roles

Nurses who transition into the role of case manager bring with them
inﬂuences of the care giving contexts in which they were trained and socialized.
Participants’ descriptions about past role contexts that contributed to difﬁculty in
making the transition from care giver to case manager include these four
elements: (a) physical task requirements, (b) focus on immediate healthcare
needs, (0) limited decision making responsibility or opportunity, and (cl)
specialization. A predominance of these elements in the previous work
experience of new NCMs appeared to contribute to role strain in the transition to

their new role.

Contextual Elements Of Present Roles That Moderate Role Strain.

Contextual elements of present roles that seem to moderate role strain for
nurses making the transition from caregiver to case manager include: (a) relevant
learning resources and reference material, (b) access to colleagues and mentors,
(c) manageable caseload. The extent to which these elements are present in

CM contexts appear to inﬂuence the ability of new NCMs to moderate role strain.

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Participants explain that access to what they feel are relevant Ieaming
resources and reference materials contributes to their ability to deal with role
strain. They agree that their current work contexts provide them with access to a
number of resources and reference materials. Some of these are relevant to the
Ieaming needs of new case managers and some are not. Though they perceive
their initial training experiences with varying degrees of satisfaction, they have
come to recognize the utility of a number of resources available to them that
some were not aware of initially.

Karen, for example, remarks that she didn’t realize “ how much of a body
of knowledge on case mangement was out there.” Her initial orientation included
more about company polices --as did other participants’ - than speciﬁcs about
CM as an area of practice. At this stage of her career in CM she is looking for
more relevance than procedure and policy manuals, and further adds, “ The
more you get into it, the more you know what is out there that you don’t know
about yet.”

By and large, participants take advantage of the ﬂexibility that the CM role
affords them to pursue their interests in Ieaming about medical as well as
insurance related issues. To the extent that participants are aware of relevant
resources within and without their respective organizations, this element of the
CM contexts serves to reduce role strain.

Interview data suggest that CM contexts generally provide new NCMs with
access to colleagues and mentors. This moderates role strain by offering formal

and/or informal support as they learn from successes and errors their new role.

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Participants who regularly met with supervisors or colleagues to discuss cases
found the opportunity to exchange stories and ideas invaluable for interpreting
their new experiences. Belinda found that the experience of handling her own
caseload was made more meaningful with the interactions she had with
colleagues. She ﬁnds what was most effective in learning to function as a case

manger was:

...probably a combination of coming in here and doing it everyday -
even though I wasn’t sure what I was doing - and the constant
ability to draw from the people I work with; the nurses and the claim
reps and the unit people that | work with. I’ve picked up an
immense amount of knowledge and abilities from them, and that, I
think, can make or break a job...lf you know nothing about what
you’re doing, you have got to rely on the people around you who
do, and you have to be able to pick out the ones who do know...
from the ones who don’t. And I have a good group of people. The
nurses here have been very willing to share what they know,
discuss a ﬁle...Everybody here has been willing to tell me, answer
my questions, show me the way, point me the way, and I think
that’s probably the biggest thing that’s led me to be able to say, “
Yeah, I’m a case manager!”

Some participants who practice on-site CM ﬁnd it difﬁcult to connect with
colleagues and supervisors while working in the ﬁeld. However, being in the ﬁeld
allows them to network with case managers, healthcare providers and vendors
outside of their organizations, which provides some interactions beneﬁcial for
learning aspects of their role.

Participants who felt that their work context supported a manageable

caseload in the beginning of their transition also felt that they were able to

confront new situations with sufﬁcient time and support for Ieaming and

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reﬂection. This helped them to accommodate to changes they experienced in
focus, tasks, and tools from previous roles as caregivers.

Donna explained how her supervisor’s consideration for her need to get
acclimated to her ofﬁce before taking on cases to manage worked for her in the
beginning, and speculated that too many cases for fellow trainees seemed to
impact their success in the transition.

I think you need to have enough time to get your ofﬁce in place

before you get overwhelmed with cases, and having not a huge

case load to start with out of training. When I was in Florida

training before we left, on our laptops you could see cases already

listed. Some of the case managers next to me had eight, ten,

twelve cases that they knew they were going back to. I didn’t have

any from...my supervisor, and I’m still on board. Some of those

people [I trained with] aren’t. So retention might be affected, might

be improved [by considering the impact of too heavy a caseload].

Work contexts that offer new NCMs environments that are conducive to
effective transitioning from the role of caregiver incorporate elements that are
sensitive to their needs as adult Ieamers. Three such elements identiﬁed by
participants are (a) relevant information and reference material, (b) access to
colleagues and mentors for feedback and discussion, and (c) manageable
caseloads. The extent to which nurses are exposed to these elements in their
new work environment appears to positively impact their success in expanding
existing knowledge and skill to accommodate new role expectations.

This section presented data that demonstrate how combinations of nurses’
past and present practice contexts may serve to either moderate or contribute to

role strain in this transition. Elements of care giving contexts that inﬂuence the

transition from caregiver to case mangers by contributing to role strain include

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those areas of focus and task requirements that are necessary for providing
physical care, but do not translate as effective strategies in case management
contexts. Elements of case management contexts that inﬂuence the transition by
moderating role strain include those that are sensitive to individual Ieaming
needs of professionals who have knowledge and skills, yet require some
guidance and validation. These needs include a balance of new information,
practical application and feedback in order to for them to face the discomfort of
being novices again. Understanding this dynamic can assist nursing educators

and trainers in assessing learning and socialization needs of new NCMs.

Summary

The ﬁndings of this study help us to understand how nurses who are
primarily trained as caregivers, transition to and learn in the role of case manger.
Analysis of collected data reveals information about motivations, expectations,
sources of role strain and job satisfaction and learning resources that are
characteristic of nurse case managers who participated in this study.

Characteristics of this role transition can be summarized as follows.
Nurses who make a practice -based career change from the role of caregiver to
the role of case manger are generally motivated by dissatisfaction with aspects of
the caregiver role or work conditions in their current employment setting. They
enter the role of case manager with expectations of relief from undesirable

conditions. They do not, however anticipate aspects of the case manger role that

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may cause strain or have a vision of how this role may provide opportunities for
them to grow professionally.

Sources of role strain that they encounter are consistent with four major
tensions: (a) time -task orientation, (b) interactions and relationships, (c)
business culture and objectives, and (d) professional identity and self-image.
New NCMs must accommodate assumptions and approaches learned as
caregivers to fulﬁll expectations associated with the role of case manager. The
process of accommodating assumptions and approaches from care giving
experience not only contributed to role strain, but also stimulated professional
growth and eventually contributed to job satisfaction for many.

Five signiﬁcant sources of job satisfaction are identiﬁed by new NCMs: (a)
facilitating recovery and impacting health outcomes, (b) opportunities to expand
knowledge and skill, (c) enhanced professional growth and conﬁdence, (d)
expressions of appreciation from others, and (e) autonomy. Autonomy, though
enjoyed by many in this role, was also identiﬁed as contributing to stress,
particularly if new NCMs felt left alone to learn strategies for efﬁciency and
effectiveness in the role.

Initial learning experiences for new NCMs involve various combinations of
formal and informal orientation and training programs, individual instruction and
on the job experience. Despite training opportunities offered or allowed by
employing organizations new NCMs often feel left to their own ill-informed
discretion to seek out and select information and experiences that will help them

develop competence. With signiﬁcant time on the job, however, and access to

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85

IC

more experienced NCMs for observation and dialogue some manage to gain
conﬁdence in their ability to facilitate their own professional development.

Data analysis also contributed to an understanding of elements of context
associated with past and present roles that are inﬂuential in NCMs experience of
role transition. Elements of past care giving contexts that inﬂuence the transition
experience for nurses include (a) physical task requirements, (b) focus on
immediate healthcare needs, (c) limited decision-making responsibility or
opportunity, and (d) specialization. The extent to which these elements were
present in previous work contexts appears to contribute to role strain in the
transition to case manger. Elements of present case management contexts that
inﬂuence the transition experience include (a) provision of relevant job
information and reference material, (b) access to colleagues and mentors for
feedback and discussion, and (c) manageable caseloads. The extent to which
new NCMs appreciated these elements in their present work context appears to
moderate role strain in this transition.

Results of this study demonstrate how nurses who make a practice-based
career change from caregiver to case manager experience the transition, and
identify inﬂuences in the process. The implications of this information for
designing education and training programs for nurses entering the ﬁeld of case

management will be discussed in Chapter Five.

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CHAPTER FIVE - Discussion

Introduction

Nurses’ experiences of change from one professional practice context to
another provide examples of the type of expert to novice transitions that are
becoming more frequent in professional life. This study explored how nurses,
who are primarily trained and experienced as caregivers, transition to and learn
in the role of case manager. Findings suggest that there are factors associated
with nurses’ experiences of this transition that have implications for the
preparation and support of nurses going into the practice of case management
speciﬁcally, as well as for those involved or interested in professional
development in general.

In this chapter I will revisit the conceptual scheme used to inquire about
the process of this expert to novice role transition and discuss the contributions
and limitations of each theoretical frame in exploring characteristics of this role
transition. I will then identify and discuss themes emerging from the data that are
speciﬁc to role transitions for nurses entering the role of case manager and how
those themes can inform the design of education and training agendas
associated with this group of professionals. Finally, I will discuss the signiﬁcance
that ﬁndings of this study hold for the practice of professional development and

further research in this area.

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Revisiting the Conceptual Scheme Used in this Study
There are several lenses with which to view role transitions. For this
particular study, a conceptual scheme consisting of multiple theoretical models
was used to inform the research questions and guide the scope of inquiry.
Findings of the study satisfy theoretical assertions offered by each model, and
support the relevance that the application of multiple models, as opposed to one

model alone, holds in this type of inquiry.

 
     
 

Care Giving

Role
-‘ I Transition

Role , Consequences
Strain ‘

‘- I‘ \ Experiential

Leamina

 

      
 

 
 

Antecedent Reactions

    

    

Conditions

i‘. .‘

 

 

 

    
  

 
  
 

Figure 4. Conceptual Scheme of Study combines the inﬂuences of past and present role
contexts with Allen & van de Vliert’s Model of Role Transition (1982), and Kolb's Model of
experiential Ieaming as a reaction to role strain.

The multidimensional conceptual scheme for this study (see Figure 4)
incorporated Allen and van de Vliert's Model of the Role Transition Process
(1982), the theory of situated cognition (Brown et al, 1989; Lave et. al, 1999;

Wenger, 1998; Wilson, 1983), and Kolb's model of Experiential Learning (1984).
128

     
  

Elements of each theory contributed to a comprehensive framework for
examining the experience of transition and Ieaming for nurses participating in this
study and perhaps for examining the experience of other professionals in
practice-based role transitions. This section will discuss speciﬁc applications and
limitations of each theoretical component of this framework.

Allen and van de Vliert’s Model of the Role Transition Process (see Figure
1), served as a useful guide in exploring aspects of the transition process that
proved to be signiﬁcant to participants in this study. Component parts of the
model; antecedent conditions, role transition, role strain, moderators, reactions,
and consequences, identify signiﬁcant facets to explore and examine in the study
of role transition. With this model as a guide, I explored facets of the transition
process from initial motivations and expectations (antecedent conditions),
changes in activities (role transition), perceptions of personal experiences (role
strain), Ieaming and accommodations (reactions) and job satisfaction
(consequences). I was also able to attend to personal and environmental
variables (modiﬁers) that explained variations in the experiences of role strain
and job satisfaction for individual participants. Utilized alone, however, Allen and
van de Vliert’s Model of the Role Transition Process fails to demonstrate roles in
unique contexts and therefore does not adequately direct attention to contextual
inﬂuences of past and present roles that contribute to role strain.

The theory of situated cognition (see Figure 2) adds a dimension to Allen
and van de Vliert’s model by directing attention to contextual factors associated

with past and present roles that can create tension for individuals in transition

129

between the two. For nurses making the transition from caregiver to case
manager, factors associated with the professional contexts they exited and
entered demonstrably contributed to tensions or role strain. Though the
component of modiﬁers (personal or environmental factors that impact role
strain) in Allen & van de Vliert’s model could feasibly handle contextual
inﬂuences, situating modiﬁers in particular contexts lends a perspective that
tensions may be characteristic of role transitions between speciﬁc contexts.
Discovery of tensions that are created between speciﬁc contexts and modiﬁers
that serve to diminish or escalate these tensions can help facilitate more
comprehensive training and socialization agendas.

The incorporation of Kolb’s Model of Experiential Learning (see Figure 3)
into this conceptual scheme allows for attention to learning as a signiﬁcant
reaction employed by professionals in the face of role strain. This was
demonstrated by the data. This model demonstrates a cyclical process of
learning from experience that includes concrete experience, reﬂective
observation, abstract conceptualization, and active experimentation.

Though it was difﬁcult to elicit discussion with participants about discreet
steps in their learning process, it was clear that they relied on experience,
reﬂection, conceptualization and experimentation to achieve their current levels
of role understanding and competence. It was also clear that they sought out
experienced NCMs and others to assist them in the processes of reﬂection and

abstract conceptualization, and appreciated structured opportunities, like case

130

presentations and ﬁle reviews to consider new case management strategies,
when they were offered.

Alone, Kolb’s model does not address motivation to learn. Incorporated
with the Model of Role Transition, however, it becomes a reaction to role strain,
and demonstrates a process of on-the job Ieaming. It also highlights vantage
points for training interventions, like guided reﬂection, conceptual discussions,
and introduction of experimental strategies that educators and trainers can
capitalize on when motivating tensions associated with the new role arise for the
learner.

Though there are several ways to examine issues associated with
professionals making career moves, the conceptual scheme assembled and
utilized here provided attention to signiﬁcant factors and inﬂuences in the role

transition experience of participants of this study.

Themes Emerging from Data
Literature on role transition suggests that the ease with which new roles
are assumed and executed is inﬂuenced by three factors: (a) the degree of
discontinuity between old and new behaviors, (b) the accuracy of the
transitioning person‘s anticipation of problems that will be encountered by shifting
behaviors, and (c) the extent to which role entry and the assumption of new
behaviors is formally structured and guided (Allen and van de Vliert, 1982).

Themes emerging from this study, which support these assertions, hold

131

implications for preparing nurses to assume case manager roles, and supporting
them in the transition process.

Interview and focus group data suggest that the following themes
characterize experiences of transition for professional nurses who enter the role
of case manager.

1. Nurses experience varying degrees of discontinuity in performance
expectations between care giving and case management contexts.

2. Nurses do not anticipate the nature of problems they will face in fulﬁlling
performance expectations of case managers.

3. Nurses often feel left on their own to determine the signiﬁcance of new
information and experiences.

4. Nurses react to role strain with attempts to enhance their competence through
seeking information and examining experience.

5. Nurses are resourceful in getting their learning needs met, yet they beneﬁt

from guidance and support from more experienced case managers.

The ensuing discussion will examine each of these themes in light of what is

implied for the education and training of nurses entering this ﬁeld.

1. Nurses experience varying degrees of discontinuity in performance

expectations between care giving and case management contexts.
Participants in this study came from various care giving backgrounds,

encompassing a variety of medical specialties, physical settings and practice

opportunities. This study suggests that nurses bring a knowledge base and

132

various skills and attitudes from their care giving pasts that can create varying
degrees of tension in assuming this new role. In addition to Ieaming new
approaches, priorities and operating assumptions, new NCMs face challenges to
assumptions and approaches that were effective and supported in previous role
contexts. As Ashforth (2001, p. 190) points out, “Part of the challenge of Ieaming
a new role is unleaming goals, values, beliefs, and norms that are antithetical to
the new role.”

Ann and Ginger, for example, found that their approach to work
assignments, Ieamed in the context of emergency nursing, carried over into their
initial attempts of case management for a worker’s compensation (WC)
insurance carrier. In some respects, their inclination toward immediate response
and task accomplishment actually thwarted their ability to manage a caseload
efﬁciently. They had to change their time-task orientation in order to function
efﬁciently and feel competent.

Nurses entering the role of case manager need to be aware of the degree
of discontinuity that exists between performance expectations of past and
present roles Educators, trainers and supervisors can assist them with an
assessment of past and present performance expectations in areas of time-task
orientation, interactions and relationships, and workplace norms and objectives.
This type of assessment will provide educators, trainers, supervisors and new

NCMs with a compass for directing learning efforts.

133

2. Nurses do not anticipate the nature of problems they will face in fulﬁlling
performance expectations of case mangers.

This study suggests that nurses moving into case manager roles are
seeking relief from undesirable aspects of care giving roles or work settings.
This motivation creates expectations for a better employment experience.
V\ﬂthout much more than an awareness that their clinical expertise is expected to
be useful in case management, participants had little, if any, awareness of the
problems they would face in pursuit of competence in this new role. This
expectation may belie a need to accommodate certain assumptions and
approaches they have utilized effectively in past roles

Irene, for example, was looking for a more lucrative employment option.
Knowing that a NCM position with a WC insurance carrier offered a better
compensation package than she realized in her position at a pediatric clinic, she
made this career move. Once in the role of case manager, however, she
encountered a number of difﬁculties, including acclimating to a business culture
and reconciling her work with her self-image as a caregiver, that she did not
anticipate and which negatively impacted her transition experience. In contrast,
Fran was more familiar with the role through her interactions with NCMs in the
context of her experience in utilization review. She appropriately anticipated her
learning curve and was able to adjust without the degree of role strain
experienced by Irene.

Being aware of the type of problems characteristically encountered by

nurses entering the role of case manager from the role of caregiver enables

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educators, trainers and new NCMs to anticipate potential sources of role strain
with greater accuracy. This allows for more informed approaches in assessing
Ieaming and socialization needs. An assessment of how accurate new nurses’
anticipations are with regard to the problems they may face in making the
transition to case management will provide educators and trainers with insight
into what the Ieamer will perceive as necessary to learn. Conﬁrming, correcting,
or informing their expectations will help new NCMs seek out and take advantage

of learning opportunities that will best serve their learning needs.

3. Nurses often feel left on their own during this transition to determine the
signiﬁcance of new information and experiences.

Collected data suggests that nurses Ieaming to function as case
managers discover various dimensions of this role from unstructured and
unplanned experiences. Participants acknowledged that they were provided with
ample information from employers about company policy and procedures,
speciﬁc lines of business (insurance, managed care, etc,) and instruction in
computer software programs. They reﬂected, however, that they felt unguided in
determining work priorities and efﬁciencies, in negotiating relationships, in
acclimating to the business norms, and in reconciling their professional identities
and self-image to accommodate unfamiliar assumptions and approaches.

Research has advanced the notion that organizational socialization
involves transformation of several aspects of newcomers behaviors, values and

attitudes. Speciﬁcally, these aspects have been identiﬁed as (a) development of

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work skills, (b) acquisition of appropriate role behaviors and (c) adjustment to
group norms and values (Feldman, 1989). Provision of new information about
policy and procedures, lines of business, and tools required for task execution,
therefore, is not sufﬁcient to facilitate role transition. Issues of group norms and
values must be addressed as well.

New NCMs require information about the nature of behavioral changes
needed to fulﬁll performance expectations of this new role. They also require on-
going support to acclimate to norms and values of the work place setting in
particular, and to case management conventions in general. Educators, trainers
and supervisors should address aspects of behaviors and perspectives from
previous roles that require adaptation to new role expectations. Facilitated
discussions addressing issues of time—task orientation, interactions and
relationships, business culture and objectives and professional identity, and self-
image will provide new NCMs with a forum to voice their concerns, questions and
impressions of their new role. Acknowledging their experiences of role strain as
characteristic in this transition should help them to gain a sense of belonging and

validation in their progress toward competence.

4. Nurses transitioning from the roles of caregiver to case manager react to role
strain with attempts to enhance their competence though seeking information
and examining experience.

Allen and van de Vliert (1982) explain that reactions to role strain can be

classiﬁed as either accommodations to self or accommodations to the

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environment. This study suggests that nurses entering the case manger role are
intimidated, albeit stimulated, by their new work contexts. As a consequence,
they are intent on discovering ways that they can become competent in their new
role and take initiatives to Ieam. That is, participants sought to accommodate
themselves through learning in order to ﬁt NCM role expectations, rather than
arrange their new role to ﬁt existing competencies or personal desires.

In describing adult learners, Knowles (1980) explains that adults have a
characteristic learning orientation toward problems and interests that hold a
speciﬁc relevance with their obligations and aspirations. That is, adults are ready
to Ieam what they perceive is needed for them to perform necessary tasks, solve
practical problems or gain personal satisfaction. Participants in this study portray
their Ieaming strategies as two-fold. New NCMs seek out learning opportunities
such as formal presentations and published guidelines and explanations to ﬁll
information gaps that they perceive as limiting their effectiveness. They also
examine their experiences of relative success and failure to gauge their
proﬁciency.

To ﬁll information gaps, Belinda takes advantage of company sponsored
programs on insurance-related topics in order to understand adjusters’
perspectives. Cathy uses her nursing textbooks and the Internet to research
unfamiliar medical issues associated with case assignments. Donna networks
with other case managers to ﬁnd work efﬁciencies in the way of forms or logs that

can help her capture her activities efﬁciently for recording billable hours.

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To gauge their proﬁciency in their new roles, participants examine their
experiences for the amount of discomfort that certain tasks or responsibilities
produce for them and the case outcomes in which they feel they have been
instrumental. As previously presented, Kolb’s Model of Experiential Learning
(1984) depicts learning from experience as a cyclical process involving concrete
experience, reﬂective observation, abstract conceptualization and active
experimentation. This process is evident in participants’ descriptions of Ieaming
from experience.

For example, as a result of examining her experience with reluctant
parents of pediatric patients, and actively experimenting with her approaches,
Evelyn became proﬁcient in establishing rapport with them over the phone by
changing how she introduces herself. As a result of examining her experience
with judging claimants’ trustworthiness, and actively experimenting with her
assumptions, Belinda became proﬁcient at collecting facts that contributed to
more accurate assessments.

Participants of this study provided ample evidence of their enthusiasm for
expanding their knowledge base and gaining new skills. This suggests that the
provision of relevant information or resources and encouragement for examining
experiences is a sound education and training strategy. Noe & Ford (1992)
suggest that two assumptions underlie the recognition of experiential or job—
oriented learning as a viable training strategy. The ﬁrst assumption is that
challenges encountered on the job stimulate or force learning to occur. The

second is that expansion of knowledge and skill are most likely to occur when

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there is a discrepancy between knowledge and skill relied upon in past roles and
the knowledge and skill required for competent execution of new role
responsibilities. The implication for educators and trainers is to capitalize on new
NCMs’ enthusiasm for Ieaming by allowing a reasonable amount of tension to
stimulate their need to know, and at the same time providing guidance and

accessibility to relevant Ieaming resources to help them to satisfy this need.

5. New NCMs are resourceful in getting their Ieaming needs met, yet they beneﬁt
from guidance and support from more experienced case managers.

This study suggests that nurses entering the role of case manager have
extensive formal and informal learning experience from past roles Though they
pride themselves with being apt learners, they are not conﬁdent in their ability to
assess their own learning needs or to direct their inquiries to the appropriate
resources in this new role.

Their thinking and Ieaming has been situated in care giving contexts,
which do not provide perspectives that are altogether useful in situations that
they encounter as case managers. In lieu of a comprehensive understanding of
the case management process or the business environment in which they now
must function, new NCMs draw perspectives and strategies from past experience
when they need to expand their knowledge base or enhance their professional
skills. This may be problematic because knowledge and Ieaming do not easily
transfer across contexts (Lave et. al, 1999; Wenger,1998; erson,1983). As

Rogoff, asserts, “context is an integral aspect of cognitive events” (1999, p. 3).

139

Although nurses entering the role of case manager have achieved
expertise in care giving roles, and have utilized successful learning strategies to
achieve that expertise, it does not necessarily follow that they are aware of what
their learning needs are in an alternative practice context or how to effectively go
about achieving expertise. This study suggests that new NCMs ascribe
signiﬁcant learning beneﬁts to interactions with and guidance from expert case
managers who understand the context in which they are now working. This
implies that guidance and support from knowledgeable mentors helps new NCMs
align their thinking and develop skilled judgement that meets performance
expectations associated with the case manger role. This in turn helps direct their

selection and utilization of appropriate learning resources.

Recommendations for Preparing and Supporting Nurses in Transition.
This study illuminated characteristic sources of role strain or tensions

experienced by nurses in transition from caregiver to case manager.

 
    
  

  
 
  
   
 
 

Time-task Orientation

     
   
    

Care
Giving
Context

Case
Management
Context

   

Interactions and Relationships

  
    

Business Culture and Objectives

Professional Identity and
Self Image

    

Figure 5. Tensions described by nurses in role transitions from caregiver to case manager.

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Collectively, these tensions are associated with time-task orientation, interactions
and relationships, business culture and objectives, and professional identity and
self-image. Figure 5 illustrates this ﬁnding. Though participants experienced
varying combinations and degrees of these tensions, data clearly demonstrate
common experiences of role strain stemming from expectations and acquired
expertise in past role contexts, and expectations and relative inexperience in new
role contexts.

These tensions, associated with characteristic sources of role strain, have
the potential for motivating growth and development on the one hand, or eroding
self-conﬁdence, delaying effective problem solving and negatively impacting job
satisfaction on the other. Preparing nurses for these tensions and structuring
support for them during the transition process will feasibly help them to better
understand their Ieaming needs, take advantage of opportunities for professional
growth and development, and expedite their achievement of new competencies.

Those with interests in the performance of NCMs should weave the
following items into the fabric of education and training agendas: (a) assessing
the differences in individuals’ past and present performance expectations, (b)
alerting new NCMS to tensions that may be created in moving from a care giving
context to a case management context, (c) informing them about relevant
learning resources, (d) and guiding them in discovering the meaning of new
expenences.

Facilitating a series of discussions between new and experienced NCMs

can provide an effective venue for assessing, alerting, informing and guiding new

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NCMs in their transition process. This type of forum lends itself to what Brufee
(1993) refers to as reacculturation, which is a Ieaming process for individuals
who leave one knowledge community and enter another. Nurses entering the
role of case manager from the role of case manager need to establish new
allegiances, gain new perspectives, and attend to new priorities. Planning
conversations about differences in experiences and expectations between past
and present roles can expose new NCMs to the perspectives and wisdom of
experienced NCMs, allowing them to voice their questions and concerns and

assisting them with assigning meaning to their new experiences.

Implications for Professional Development

The need to examine role transition for professionals in today's workforce
arises because of the evolution of employment opportunities. Advances in
knowledge and technology and changes in resources and consumer
expectations have not only precipitated creation and elimination of some roles in
the workplace, but have also inﬂuenced practice alternatives in traditional roles.
Nursing is a profession that has realized practice alternatives and changing
employment opportunities for its members. This study of nurses entering the role
of case manager provides an example of how professionals experience and learn
in transition and offers considerations for effective education, training and
socialization strategies that can be applied in other professional role transitions.

As this study demonstrates, role transition actually involves more than

changing from one patterned set of behaviors to another. Old and new behaviors

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are enacted in contexts that encompass unique expectations, perspectives,
priorities, social networks, tools and personal meanings. Professionals who have
been educated, trained and extensively socialized through years of experience
with particular practices and perspectives face the arduous challenge of letting
go or accommodating hard-earned competencies in the wake of evolving practice
standards and career directions. Continuing professional education (CPE) needs
to address this challenge.

Nowlen (1988) describes three model approaches that characterize
current CPE practices; (a) the update model, (b) the competence model, and (c)
the performance model. The update model consists of providing the learner with
information-intensive resources such as instructional or explanatory reading
materials or symposia presentations. Adequate for imparting new or updated
information relevant to practice, the update model fails to address the skills
required for putting this knowledge to use.

The competence model combines information with skill building in such
areas as critical thinking and interpersonal relationships that are necessary for
individuals to function competently in a particular role. Adequate for directing
attention to the skills required to apply knowledge, the competence model fails to
address the larger factors that inﬂuence performance like environments and
cultures of practice, past experience and life skills, and preparation and support
in new roles.

The performance model addresses the shortcomings of the other two

models and promotes a process of guiding professionals, as well as

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organizations, in self- assessments concerned with a broader range of issues
associated with performance. The product of guided self-assessments is
personalized,or organization-speciﬁc,learning agendas that provide direction
toward meaningful Ieaming experiences aimed at enhancing performance. This
model offers the most promise for adequately preparing and supporting
professionals for and in the process of role transitions.

The promise of the performance model lies in its attention to signiﬁcant
issues associated with role transitions that inﬂuence performance. These issues,
which include past experience, role relationships, and cultural perspectives, are
not traditionally dealt with in CPE or job orientation programs. Findings of this
study and the subsequent recommendations for preparing and supporting nurses
in role transitions are consistent with this model and, no doubt, have practical
applications for other professionals in transition.

Educators, trainers and supervisors should address the experience of
expert to novice transitions in job orientation and mentoring programs.
Specifically, a guided assessment of the differences in past and present roles
and expectations should be explored with professionals in transition. Their
anticipation of problems should be discussed and conﬁrmed or corrected. They
should be alerted to tensions commonly experienced, as well as opportunities for
professional growth, associated with this transition. They should be guided in
locating and selecting learning resources that can help them learn to function
efﬁciently and conﬁdently in their new role. They should be supported in dealing

with change and the discomfort of expert to novice transition.

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Suggestions for Future Research

Some ideas for future research have emerged as a result of studying the
experience of role transition for nurses and other professionals. Speciﬁc to this
professional population, expanding the sample to include a larger number of
participants from various geographic areas and case management contexts
would certainly serve to validate or add new perspectives about this experience
for nurses. Including male representation in the sample might demonstrate some
variation in transition experiences between genders. It would also be interesting
to examine how the stories of transition are similar or different among people of
speciﬁc age groups or years of experience.

Additionally, investigation into the assumptions that educators, trainers
and supervisors have about experienced nurses coming into the role of case
manger and their expectations for how quickly they are expected to function
independently would add to our understanding of the transition process from
another perspective. It could also contribute to better training of the trainers, by
identifying potential disconnects between trainers' assumptions about the
transition process and the actual experience of new NCMs.

Pertaining to a broader professional population, this conceptual scheme
could be used to explore expert to novice transitions between other professional
practice contexts, such as business to academia, private medical practice to
public health administration, industrial engineering to corporate leadership, etc.

Identifying characteristic tensions between speciﬁc role transitions would

145

certainly provide added value for education and training programs directed at

professionals in transition.

Conclusion

I engaged in an inquiry of how nurses, who are primarily trained and
experienced as caregivers, transition to and Ieam in the role of case manager.
From observations and conversations with these nurses, I developed a sense of
their struggles and rewards in assuming new role responsibilities. While results
of this study do not surprise me, this endeavor has helped me to understand the
nature of their struggle more comprehensively and to see their journey toward
competence more clearly.

It has also informed an approach in educating and training nurses and
other professionals who enter alternative ﬁelds of practice that extends beyond
deﬁning a core knowledge base to be learned. It has identiﬁed areas to explore
with transitioning professionals that will help them anticipate potential tensions
and triumphs that may lie ahead, and develop plans for encountering them. This
study highlights an example of professionals in expert to novice transitions and
inform the larger ﬁeld of professional development and those with interests in

enhancing professional performance.

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APENDICES

147

APPENDIX ONE

Interview Protocol

148

INTERVIEW PROTOCOL

Logistical Information:
Age _
Education __
Years of practice as a caregiver __
Years of practice as a case manager _
Where on a scale of 1-5 (1= novice; 5 = expert) do you rate your level of
expertise in CM?
Work experience other than nursing

1. Tell me about the different contexts in which you have practiced as a
professional nurse.

3. How would you describe the principle differences between the practice
context of a caregiver and that of a case manager? (ie, rights,
responsibilities, resources, support structure, etc.)

b. How do the resources that were available to you for learning to provide
hands-on nursing care compare with the resources that are (were) available to
you for Ieaming to function as a case manager?

2. Describe what the transition from caregiver to case manager was like for you.

a. What motivated you to make this career change?

b. Where does this role ﬁt in your career plan?

c. In what ways have your clinical knowledge and care-giving experience

prepared you to assume the role of case manager?

d. Which expectations and responsibilities that you associate with the role
of case manager did (do) you feel least prepared to fulﬁll?

e. Describe the sources of conﬂict or strain that you experienced in
assuming and developing in the role of case manger? What aspects of
this role continue to cause you concern or discomfort?

f. What types of environmental or personal accommodations make you
feel more comfortable or conﬁdent in the role of case manager?

9. What do you ﬁnd satisfying or rewarding about case management?

149

3. How did you go about Ieaming to practice case management?

a. Which experiences do you recall as signiﬁcant in your learning in the
following areas described as the core knowledge domains of CM:

1. Coordination and healthcare delivery systems

2. Physical and psychosocial factors

3. Beneﬁt systems and cost analysis

4. Case management concepts

5. Community resources
b. What have you learned essentially through formal means (i.e. pre-

service courses, in-service or continuing education programs?)

c. What knowledge and skill have you essentially achieved through
eXperience? Describe how that learning occurred.

d. What opportunities do have to review or discuss cases for the purpose
of increasing knowledge or improving performance?

e. How have your conclusions or beliefs about what constitutes effective
CM been challenged during your career?

f. In what ways has your practice of CM been impacted by formal and
informal Ieaming since assuming this role?

9. Looking back over your experience of role transition from caregiver to
case manager, what was most helpful in terms of socialization and
learning?

h. What additional or alternative types of support would have more helpful
to you in making this transition?

150

APPENDIX TWO

Participant Consent Form

151

Role Transitions for Nurses: From Caregiver to Case Manager

Participant Consent Form

The objective of this study is to explore how nurses make the transition from the role
caregiver in a provider setting to the role of medical case manager in a payer setting.

As a volunteer participant you will participate in two taped interviews (approximately 60-
90 minutes each) about your experiences and perceptions of how you learned to
function in your role as a case manager. You may also be asked to participate in a small
group discussion with other volunteer subjects on common themes that the investigator
gleaned from individual interviews. In total , the amount of your time required over the
course of the study should not exceed 3-4 hours. All meeting times will be scheduled at
times mutually agreeable to investigator and subject(s).

Your participation is strictly voluntary. You may refuse to answer questions or discuss
topics at your discretion. You may withdraw your involvement totally or in part, or
withdraw personal data collected at any time prior to the ﬁnal written report of the study
without penalty or loss of beneﬁts to which you are othenrvise entitled.

Conﬁdentiality for subjects will be maintained. Your privacy will be protected to the
maximum extent allowable by law. Your personal identity will not be made explicit in any
written report or commentary that is submitted for publication.

You have the right to review written transcripts of any interview during which you were
recorded upon request.

Any or all of the following people are available for you to contact with any questions or
concerns that may be raised by participation in this study:

Ashir Kumar, MD, Ann Austin, PhD Nancy Schmitt, M.Ed.,
Chair, University Responsible Project RN, CCM
Committee on Investigator Project Investigator
Research Involving Michigan State Michigan State
Human Subjects University University
Michigan State 517 355 6757 517 540 4997
University

517 355 2180

l have read the above and volunteer to participate in this study.

 

 

Signature Date

152

APPENDIX THREE

Participant Proﬁles

153

ANN

Participant Proﬁles

Ann is a 53-year-old NCM. She has been doing telephonic CM for 3

workers' compensation carrier for the past year and a half. She is a coworker of

Irene, Ginger, and Belinda. She explains her role in the following way.

I have a major responsibility in that l have to make the adjuster
aware of what is going on with the person...They have no medical
background, so I have to be able to relate that to the [claim adjuster].
And also relate to the physician...When the physician orders
something I have to be able to relate to the [claims adjuster] why this
is appropriate or why not and I have to be able to build my case on
it.... - why we should do it, why we shouldn’t. And in turn I have to
go back to the physician and say "You know what? This isn’t
appropriate. Where are you coming up with this?" and have him be
responsible to tell me why this is necessary.

I tell [claimants] that I am their nurse case manager, and that my
role is to get them back to work and make sure that they get the

treatment that they deserve and that they require in order to get

back to work.

Ann came into her current role with 30 years of nursing experience, mostly

in the emergency room. Though she did some work in hospice and a physician’s

ofﬁce,

she spent 27 years as a caregiver in critical care and emergency settings.

Compared to her care giving experience, Ann ﬁnds the CM experience very "laid

back.”

No one is going to live or die if you don’t do something. If you don’t
get that report [today], [you can] get it tomorrow. Where as in the
hospital, if you didn’t give a med [or] answer a light, someone could
die or be hurt. So it’s a lot less stressful. There’s stress in it’s own
way, but not that emotional stress, that emotional roller coaster that
you’re on in the hospital. Working in the emergency room, you
never knew what was going to come through the door so you had

154

to be on your toes every minute. In this job you can relax. It’s a
nice way to end a career.

Ann's friend, an employee of the company Ann currently works for,
informed her about an open position for a case manager a few years ago. She
considered applying for it, but decided to put that type of a career move on hold.
With what she understood of the role, she planned on making a move like this
later in her career. The physical nature of emergency nursing became an issue
in her health, however, so she took advantage the opportunity when the next
NCM position became available. Though she has described CM as more "laid
back" than her role in the hospital, the transition for her was "scary".

I had never been in an ofﬁce before. I’ve always been in
[healthcare]. I came here and it was very, like I said laid back, and
I was used to having to do x number of things before I went home.
And here ...when I ﬁrst started, ifl had a red number on my
[computer] screen which meant that these were things that I should
have done already, I was like hysterical. Oh my God! I’ve got to get
these done!" Because in that [caregiver] mind set, you don’t go
home till this is done. You know you have to get your charting done
and give your meds and make sure that patient was cleaned up
before you went home. Well here it was like "oh , ok so I’ll just do
it tomorrow." 80 now when I have 50 reds, it’s like ”Huh! I have 50
reds." I mean not that. I like to do that, but you know.

I guess that was scary, not knowing anyone. How is this job going
to affect me? ...I came from working 3 days a week to working 5
days a week. And that was a transition to not be home the extra
days. So getting my own personal life in order was a challenge,
getting my husband to cook. " Honey, I’m not going to be home."
But in the work place it worked out really well for my health. I
needed to get to a slower paced job and this was a good
alternative.

Sources of satisfaction in this role for Ann include the slower pace, the

opportunity to use her knowledge of traumatic injuries and diagnostic tests and

155

procedures. She has been given the responsibility of handling some of the more
serious injury cases and ﬁnds this very rewarding. She also enjoys the
relationships she’s been able to develop with employers, patients and physicians.
She enjoys making things happen through conversations - a strategy not often
applied in the emergency room.

Despite ﬁnding considerable favor with this job, the role of NCM holds
certain challenges for her. Working with claim adjusters presents such a
challenge.

As a nurse in the hospital, when there was a conﬂict with someone
else it was generally a lower discipline and you could say, ” I am the
nurse. You will not do this function." Here we rely on each other
more - the nurse and the claim adjuster. I can’t do my job unless
she does hers or he does his. I can’t close out a case if they don’t
put in dates. And you tell them and you tell them and it doesn’t get
done. To me that’s very frustrating. You get medical [records] on
someone, and it’s like this needs to be done. Or yes this is a
relationship. This injury could have occurred from this injury. Well,
they don’t want to see that. They only want to see the main injury.
And then there’s a problem further down the road where we could
have done something for the secondary and got the guy back to
work.

Ann considers her clinical background to have provided her with a caring
ability in this role. Caregiver experiences like ”sitting at the bedside of people,
knowing what they’re going through, having seen people go through trauma, the
stress that it puts on them," motivates her to cut through some of the red tape
and run interference for claimants.

Ann does not recall any education speciﬁc to the case management

process, only bits and pieces of content material on workers’ compensation,

156

speciﬁc injuries, etc. The training she was offered for CM consisted of two weeks
of "orientation with another NCM.”

I sat with her for the ﬁrst few days, watched her, read over the manual,
and then slowly was put into the position. [I was] given a case to work
on with her coming and checking my work and making sure that l was

where I should be and doing what I should be doing.

Ann has worked out a new dimension to her identity as a nurse.

I think I’ve gained an appreciation of a different type of nursing.
Because nursing now is branching out into every aspect of life, you
know. We have 5 nurses in our family, and we’re all in a different
area. And I’ve Ieamed a lot. I don’t think I’ve lost anything. I did my
30 years of bedside and now it’s time... A caregiver giving baths,
giving shots, that I don’t see myself in anymore. But a caregiver as
directing care, telling people it will be ok, yes, I still do that.

BELINDA

Belinda is a 49-year-old NCM who does telephonic CM for a workers’
compensation carrier. She has been in with this employer and in this role for 3
years. She is a coworker of Irene, Ann and Ginger. She has come to
understand her role in the following way.

Effective case management requires a lot of different skills. And
when I ﬁrst came here I ﬁgured well, all you’ve got to do is make
the right phone calls and you’ll be ﬁne. And that’s not the case.
There’s a lot more. There are a lot more diversiﬁed skills in being
an effective case manager than just coming in making your phone
calls, documenting that you did that and going home. You have to
be nice to people you don’t want to be nice to. You have to cajole.
You have to be observant. You have to search out information.
You have to say things that people don’t necessarily want to hear,
and you have to say it to them with conﬁdence. ...There’s just a lot
more skill involved than what it looks like. When you say ”’manage
the case” you think ok, I'll pull the case out. And I’ll make all these
calls and I’ll say "This is what I think should happen," and that will
be the end of it. But it’s the follow up, making those things happen.

157

And what it takes to make those things happen, that really is

managing the case. And that’s what you didn’t know when you ﬁrst

got into it.”

Her care giving experience actually started in high school when she
worked as a nurses’ aide in a nursing home. Belinda earned an associate degree
in nursing as a part time student, working all the while in a physician’s ofﬁce.
Belinda returned to the nursing home as a graduate nurse for a year after
completing her degree. From there she went on to work for in a general practice
clinic setting until her daughter was born. After 15 years of raising a family,
Belinda returned to work, this time in a pediatric clinic for six years. As she
reﬂects on the various responsibilities she had there she feels she actually did
some case management, though at the time would not have identiﬁed with the
role.

We were given a lot of leeway to make decisions. We contacted

doctors, followed up on necessary treatments and x-rays and

hospitalizations, things like that. All that was done from the

phone... We would start the case with the ﬁrst phone call,

especially with new babies. They called us right away and asked

us when to make an appointment. And then we were also hand

holders in that you know they called us and said, “ The baby’s

screaming and I don’t know what to do.”...Rather than have the

doctor be bothered with all of that stuff that probably moms could

handle better anyway, we were on the nurse line and that was a

separate line in that ofﬁce and that was our job all day long we

talked to the moms and dads.

The motivation for taking on the role of NCM, Belinda explains as an
opportunity that presented itself. While she did not seek out this particular

position, she was fearful that her position was in line for elimination as rumors of

budget cuts came down. A former coworker, Irene, was now working as an NCM

158

and her employer was looking to ﬁll another such position. At lrene’s suggestion,
Belinda applied and was hired. The major attraction, Belinda admits was the
salary, which was considerably more than she was being paid at the clinic.

Belinda describes her Ieaming opportunities with this employer as effective
in getting her up to speed. Along with a formal orientation program, her caseload
was built up gradually and she received regular feedback, which helped her
navigate her way through her new responsibilities.

Case management was a formal training program that my
supervisor here had put together to get a uniformity in what people
were doing, and I found it very easy to follow. We also had a
computer program that prompts you to do certain things, and that
was a very good resource. But I would say that the training that I
got here through the program that was put together was very good.
And along with experience, making mistakes, ﬁnding out who’s
good who isn’t, where to follow up, when to ask for this, when not to
ask for that.

Though Belinda was happy to have the extra earnings, and found the
learning opportunities to be a source of satisfaction, she struggled in her
transition from caregiver to case manger.

In this context your focus is not patient oriented. Your focus is
monetarily oriented. You’re more involved in following up from the
employer’s standpoint than you are of taking care of the patient,
and for me that’s a constant pull between the two. Finding a place
where I’m happy with that I’m doing the right thing for the employer
who ultimately is paying for my services, but as a nurse making
sure that patient is getting the care that they need and require.
...That was a hard place to come to. That took me a while to get
there... It’s Ieaming to respond to people from a totally different
perspective. You are not their caregiver and you are not
responsible for them to be happy and well. You are responsible to
put together the medical, to pick up the facts and deal with the facts
as they sit there. And that’s always been a part of nursing, but to
separate yourself from the warm nurturing "give me a hug and I’ll

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make you feel better" kind of caregiver that I was, that was a
transition. That was the main transition.

Belinda feels that she has Ieamed to be more assertive in this role, and that
she has grown in conﬁdence in terms of her knowledge of healthcare and
insurance. She admits she has had to loose some of the emotional attachment
she was used to having with the patients and families she interacted with as a
caregiver.

Nobody said, “Do not get emotionally involved with these people.
It’s not what you’re supposed to do.” And I don’t know if it would
have mattered anyway even if they had said it, because that’s the
kind of nurse that I am. That’s what I do, and it was trial and error
and you learned... You got pulled under the rug a couple times
with people that you had some sympathy for, and then found out
later on that they weren’t working on the jobs [at the time of injury].
And [by] the same token there were people who didn’t seem to
be sincere at all that turned out to be very sincere. And so trial and
error you learn to distance yourself. ...That doesn’t stop you from,
you know, talking to them about their grandkids or this, that or the
other thing. It’s just that ...you don’t put that emotional attachment
that you put with a patient that you are caring for in a sickness
setting that you do. Here it’s different.

What Belinda ﬁnds rewarding is being able to solve problems, to help
someone get back to work despite a long and complicated recovery process.
She likes the patient contact. She likes to follow up and ﬁnd out how her clients
are doing after surgery. She likes the relationships she has developed with
physicians’ ofﬁce staff and her newfound ability to challenge a physician when
she doesn’t see the rationale of a prescribed treatment plan.

As far as her professional identity, she still feels very strongly that she is a
nurse. She has resolved that case management is another opportunity to use
her nursing skill, but that it has provided her with an opportunity to grow
professionally as well as personally.

It’s a different job and it’s not what you think nursing is going to
be... It's not where you thought you would be as a nurse when you
graduated from nursing school. The last place I would have
expected would be sitting behind a computer at an insurance
company and still calling myself a nurse, and I do, and I am.

So it’s outside my perspective of what a nurse is and what a nurse
does... It’s what I Ieamed to do here. I Ieamed to do it here. It’s

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where I picked it up and where I’m making it sharper and making it
part of who I am, because I’m a lot more aggressive at home now
too.

CA THY

Cathy is a 29-year-old nurse who has worked as an on site NCM for a case

management company for just under one year. She manages cases from

workers’ compensation, auto, and disability insurance carriers. She is a

coworker of Hannah. She explains her role in the following way:

There’s a lot of demands being put [on] you from a lot of directions.
So the adjuster has demands of you. The physician has demands
of you in some ways because he wants the claimants to do
certain things. So basically you’re to coordinate it. The claimant
has demands of you. Being able to answer to all these demands
and sometimes being able to answer to them yesterday... When I
go to appointments with claimants and physicians, ...in a way, [I]
direct the appointment so that things get addressed. Or in
conversations with claimants [I] direct the conversation so that
certain things get addressed and don’t get lost. ...You’re directing
the conversation so that the are areas that you need addressed are
being addressed... I do a lot of teaching with my clients... I try to
make someone understand the processes that they’re going
through. And I try to encourage people to be active with their
choices as opposed to just letting the doctors and the other medical
people make the decisions and just following along. I try to
encourage them to make active choices regarding their care and to
know what those choices, what the implications are.

Cathy holds a Bachelor of Science degree in nursing. Her care giving

experience began prior to completion of her formal education in nursing. She

worked a home health aid after graduating from high school and continued

throughout the time she was completing coursework for her degree. She started

her professional nursing career in the hospital on an oncology unit. Within a ﬁve-

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year timeframe, Cathy had positions in home care, ﬁrst working for a cancer
institute, and then the Visiting Nurse Association. (VNA). Just prior to taking her
present position she worked for a county health department.

She explains her role with the cancer institute as more of a health
educator. With the VNA her role was task oriented and ”high tech”. She made
ﬁeld visits to homebound patients, who required special equipment such as
monitors, feeding tubes, intravenous lines, etc., and administered treatments,
and checked to see if the equipment was working properly. At the health
department, Cathy relates the she did a combination of hands on care -
administering medication, doing physical examinations and teaching, and some
case management- working with a speciﬁc caseload of patients, initiating contact,
setting up appointments, and following up with them over time.

Her motivation to get into case management was a desire to ﬁnd an
occupation where she could better use her education. The transition, she states,
was enjoyable.

When I was in the hospital I felt as though didn’t really need to go to

university for doing what I was doing there. You know, I felt that

anybody can come here and follow the instructions, follow these

orders that the doctors are writing in this little book. And anyone

can give this. Anyone with any kind of, you know, because you

don’t have to be educated to do this... I was upset by that. So I

feel that this is a job that I’m using my education for. I feel that it’s

a job which requires you to be more responsible, which requires

you to think through your actions more; which requires you to

actually think through the way things are moving; looking at a

bigger picture when you’re looking at a ﬁle; looking at a bigger

picture and the progression of this ﬁle. So I enjoy the transition a

lot. I enjoy being able to do this. Like I said I was upset working at
the hospital feeling like I wasn’t using my education.

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I enjoy working with clients. I know that there are claimants who
may malinger but I think that generally speaking most people want
to be well. And I enjoy when I can look at someone impartially,
maybe because I’m newer and not assume that they’re trying to
take advantage of the system, at least not assume until I’m proved
otherwise, you know. But when I can resolve a ﬁle in a way that I
feel good about this, that the claimant feels good about this
resolution, the employer feels good, and the adjuster feels good,
then I feel good. It feels good.

In terms of her career plan, Cathy speculates that she will most likely
stay with this for a while, but go back to school eventually. She is open to

entertaining other types of employment.

EVELYN

Evelyn is a 46-year-old nurse who provides telephonic case management
for pediatric members of a health maintenance organization (HMO). She has
been in her current role and with this company for close to three years. She
explains her role in the following way:

Right now I’m focusing on all the premature babies for the state of
MI. And I also have some catastrophic cases; catastrophic illness
and long term medical care cases. And what I do is, for the
preemie babies in particular, I get in touch with the mom, let them
know what’s available in the communities, the different programs
for premature babies in the communities, and then I also follow
them for the ﬁrst year of their life. I do monthly phone calls
depending on how they’re doing. Just to make sure they are up to
date on their immunizations, keeping their doctor’s appointments,
and I also coordinate the RSV program...Respiratory Syncytial
Virus... It’s a vaccine that’s been out probably a little over ﬁve years
now, and its highly recommended for premature babies during this
RSV season; which is every year from November to April. So for all
the premature babies in the state, I set up the program with the
primary care physician so that the babies can get the vaccine...
Now the other babies, the other catastrophic cases, I give ‘em a call
if I’m made aware that they’re in the hospital. Sometimes I’ll send

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Cathy attributes her Ieaming of CM to on the job experience. She relates
that she accompanied other nurses on appointments and observed. She
received fairly uncomplicated cases to begin with and received feedback form
her supervisor who initiated discussions on her assignments. As time went on,
the size and complexity of her caseload grew. She utilizes other case managers
as resources problem solving and advice.

Sources of role strain for Cathy include gaining a skill in diplomacy, and
gaining conﬁdence in her interactions with physicians.

To me it seems that in case management you have to Ieam
diplomacy because of a lot of the things that you’re dealing with
may be in litigation... Certain insurance laws that I don’t know
because I have never worked in insurance, but I ﬁnd that
sometimes I have to be careful in the way I put things. I cannot be
as straightforward as I’m used to being. I have to be a little bit
sideways, so in that way I’m not very prepared for that. That’s
something that I’m really trying to work on. For example, in
situations where there’s surveillance going on. Or when somebody
may be doing some symptom magniﬁcation, or something like that.
That I have to be careful how I should say that or whom I should
say that to type of things or how I should write it in a report, how I
should write things, how I shouldn’t write thing.

A nurse is taught, ”Don’t question the doctor.” ...You’re almost
taught this. I mean you hear stories about, you know, when the
doctor comes you’re almost supposed to get up from your seat to
offer your seat to him, you know. You’re not really, even though
they start saying more about now ”Don’t do things if the doctor
says, if you’re not comfortable with that treatment plan." Even
though you’re taught that in nursing school, ...the perception of the
doctor being someone you should almost even offer your seat to
you know, drop what you’re doing to ﬁnd them the chart is still
there. And so asking them why they’re doing one treatment as
opposed to another starts out feeling kind of strange.

Her satisfaction comes from the challenges that the role brings, contact

with her clients, and satisfactory outcomes for all stakeholders in a case

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them a letter, sometimes I won’t. Depending on how severe the

case is, I’ll just jump right in and give them a call. Or contact the

doctor and then we’ll communicate that way.

Evelyn began her caregiving career at the age of sixteen when she began
working part time as a nurses’ aide in an urban hospital during high school. She
continued this job while she attended college. After completing a Bachelor of
Science degree in nursing, she spent 27 years of her professional nursing career
in the ﬁeld of pediatrics. She gained experience working with children and their
families in hospital settings, on pediatric medical-surgical and neonatal intensive
care units, as well as in health department and HMO pediatric clinics. An ad in
the paper for a Pediatric Case Manager caught her eye at a time when she was
becoming dissatisﬁed with her position at an HMO ambulatory care clinic where
she was the nursing supervisor.

I was looking. I wasn’t really satisﬁed with the work I was doing...

The clinic there was not only primary pediatric but it was specialty,

and we had a lot of specialty and not quite enough staff to handle

[specialty cases]. We had staff of13 physicians on that one ﬂoor.

They were having some layoffs and l was looking for something. I

wasn’t really looking for case management, or I didn’t know what I

was looking for. And I saw this position and said, ”Hey, I’ll apply for

this and see what it is.” And so I’ve been here since.

The transition from caregiver to case manager was difﬁcult for Evelyn in
the sense that her job duties and responsibilities were not initially well deﬁned.
She found, however, that her clinical background prepared her well for the type
of cases she would be managing, and the questions she was getting from

members as well as coworkers.

It was difﬁcult at ﬁrst because I didn’t know what it was I was
supposed to do and what I was expected to do. Like I said, the job

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description was so general. Management didn’t know what they

wanted me to do. So that part of it was difﬁcult. Until I Ieamed

what it was that I actually should be doing, then I felt comfortable...

It probably took me close to two years to know what I was doing,

[to] feel comfortable with what I was doing, and have everybody

else feel comfortable with what I was doing. Because whenever

somebody said “pediatrics” or “kid”.... ”[Evelyn, Evelyn, Evelynlj”

But that’s not what [Evelyn] does. I had to get people used to doing

some things on their own and not coming to me with everything.

Evelyn relates that Ieaming to function in the case manager role was a
matter of observing two other “specialty” NCMs, ﬁnding out what resources were
available to help her ﬁnd answers to her questions, and then developing a role
for herself through trial and error. To develop the role of pediatric case manager,
she incorporated what she had observed of other NCMs, and made it work for
the premature babies and catastrophically ill pediatric members and their
families. She developed her own criteria for referrals and strategies for following
cases. She also Ieamed to work with parents, physicians and healthcare
vendors effectively over the phone instead of face to face as she was
accustomed to in the hospital and clinic settings.

She did not attend any training sessions on case management, but she
vaguely recalls some print material on the subject provided by her employer.
“Now, it was something, I’m trying to think if it was a magazine or something, or if
it was actually the company’s. I think it was more or less the company’s book of

what case management involves.” This, she says gave her an idea where to

start, but not explicit guidelines. Even now, in a Master’s program in nursing

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When asked about the sources of satisfaction gets from her job, Evelyn

cites the gratitude from the families with whom she works.

What I ﬁnd satisfying about it is the thanks I get from the families
when I put them in touch with other things, or when I explain to
them what their actual contract covers and that I went to the doctor
and we discussed it and yes he approved it. So it’s just the
satisfaction I get from them when they say, "Thank you. Thank you

for helping me. I’m so glad I have you here to help me I would
have never known,” you know.

Though Evelyn has experienced signiﬁcant differences between her roles
as caregiver and her role now as an NCM, she does not identify the experience
as role strain.

You know I can’t really say that there is anything that I struggle
with, that I have difﬁculty with. There are so many of us here... I
work in the Medical Management Department. Everybody that
works in medical management, from the case managers to the
patient care coordinators who actually do the utilization review for
the hospital to our transitional or comprehensive team, who does
home care, are all registered nurses. And so if there’s anything
that I have a problem with, or I need some more information about,
it’s 60 something nurses that I can go to for additional resources.
But as far as really having something about this job that’s difﬁcult, I
can’t say that there’s anything that's difﬁcult.

Some of the differences she cites include empowering parents to care for
their seriously ill or injures children at home. She shares that during the time she
was providing hands on care, she neither had the time to do the kind of teaching
and listening to families that she engages in now, nor was there an expectation
that a parent would actually provide on-going care for such children. There were
facilities to care for seriously ill or disabled children at one time. She points out,

however, “ It’s different now. They’re taking them home because there are no

167

facilities in the state to care for kids, catastrophic cases. So families have to
Ieam how to care for these children at home.”

Evelyn’s professional identity is strongly connected to nursing. She feels
that case management allows her to utilize her knowledge and skill to help
people. Even so, she admits that members are often reluctant to open up to
someone associated with an insurance company. However, she is quick to point
out that once she identiﬁes herself as a nurse, she is able to establish rapport
and make some impact.

You can hear it in their voice when I call and I say my name is

[Evelyn] and I'm a case manager at [this HMO] and [they reply],

...."Yes?”.... And you know what they’re thinking. ’Why is

someone from the insurance company calling me?” So I learned a

long time ago not to say, ”I’m calling from [this HMO], a case

manager. [Now I say}, “My name is [Evelyn]. I’m a pediatric nurse

I work for [this HMO] and I’ve been doing pads for twenty

something years." .Then they loosen right up.

Though Evelyn is very happy in her current position, and ﬁnds it to be a

good use for her skills, she shares that she may consider teaching nursing after

she ﬁnishes her graduate program.

DONNA

Donna is a 46-year-old NCM who practices on site case management for
a worker’s compensation insurance carrier. She has worked for this company for
just under a year. She came into this position having some prior experience in

case management as an occupational health nurse in a manufacturing plant.

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She explains case management as “a path that you go down with your client
together. It’s a journey.”

Donna’s clinical background includes 10 years of emergency nursing, 3
years as director of nursing at an ambulatory care clinic, and 11 years in
occupational health. Having earned an Associates’ degree in nursing, she is
currently enrolled in an RN- to- BSN program at a local university. She sees the
various nursing opportunities that she has taken advantage of as “stepping
stones” toward her present role of nurse case manager.

I think they really laid the foundation. I don’t think I could have

been an occupational health nurse had I not been an emergency

room nurse. So the foundation with emergency nursing was the

platform that I, what’s enabling [me] to perform as an occupational

health nurse because you’re doing a lot of assessment -

emergency assessment of some situations whether it be an injury

or whether it be personal, whether it’s a heart attack you have to

assess cardiac or you have an amputated foot so you have you

need those assessment skills. Not only assessment but

treatments. And how to work with an EMS system, etc. So again

my emergency nursing was the foundation for occ health. Then I

think my occupational health experience was the next layer of my

foundation that helped me be or get the job as case manager.

The closing of a plant where she had been employed for nine years forced
Donna into working for a temporary agency until she found another suitable full
time position. It was while working for this agency, in an employee health clinic
at a major automobile manufacturing plant, that Donna was approached by a

workers’ compensation insurance adjuster about an NCM position with his

company. She had become acquainted with this particular adjuster on the job at

169

her previous employer. Though it was deﬁnitely not part of Donna’s career plan
to become an NCM, she ﬁnds that it works for her.

I think it happened for a reason for what I needed, which is it works

for my family situation so much better.... I can adjust my workdays

according to what my family situation is at the time... It’s giving me

a challenge... I can develop this job to whatever I see it as my

vision of the way I want to be as a case manager.

Donna feels she came into this role with a good understanding of the job
responsibilities and the impact a case manager can make. She relates that her
company provided a two-week training program that incorporated content of
workers’ compensation in general as well as the companies policies and
procedures associated with the case management process. What was missing,
in her estimation was how to work out of a home ofﬁce and manage her time in
the ﬁeld.

Donna works out of her own home. She has been supplied with a laptop
computer, a dedicated business phone line, fax machine, and compensation for
travel expenses. While working with claimants, employers and physicians is a
good match for the skills she has developed over the course of her career, she
identiﬁes balancing time in the ﬁeld along with managing clerical duties and
maintaining ofﬁce as the main sources of role strain for her. To some extent,
working with adjusters contributes to role strain as well.

I’m more intimidated by adjusters than I am by physicians...

because I don’t think [adjusters] truly understand the situation, what

goes on in a doctor’s ofﬁce. I don’t think they truly appreciate your

relationship with your client. I think they are task oriented and less
sensitive to the dynamics of a relationship and that includes nurse

to client and nurse to physician and the dynamics from client to
physician there. And only the nurse is sensitive to that. The

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adjuster doesn’t always get a feel for that, what is actually going on.
And I think what adjusters don’t always know is how much ﬁnesse a
case manager needs in some situations to make things happen,
you know. So I think I feel like I have a harder time trying to
communicate what’s going on to the adjuster than I have to a
physician [or] to the client I have. It seems to be a better ﬂow of
information here than sometimes with some adjusters. Some
adjusters just don’t understand.

Donna’s satisfaction with this role is the ﬂexibility and the opportunity to
grow professionally.

It’s kind of like there’s no limit to me in case management. I see it
as a very nebulous. There’s no ﬁxed point [where] your job ends,
that your description ends. And you can make it as professional or
as big as you want to make it, as you have the time for. Case
management is the product. It’s a search.

FRAN
Fran is a 44-year-old nurse who has worked for a Health Maintenance
Organization (HMO) as an on site NCM for 2 years. She explains her role in the

following way.

I feel that as a case manager I need to act as a liaison between the
physician and the patient. What you’re doing is... you’re ensuring
that the [HMO member] and the physician are in agreement to the
member’s treatment and that the member can go ahead and get all
that treatment, understands the treatment is the biggy. And then
you're acting as a facilitator to make sure they get what they need.
You know, like they don’t half the time they go in to see the doctor.
I take a piece of paper and write it all down for the member...after
the visit we sit and [I’ll] say, “Well you know he said you’ve got to
decrease your salt intake. He did, you know.” [I’m] just reiterating
really what the physician’s orders are and educating the member
because they’re so nervous when they go in there.”

Fran holds an Associate's Degree in Nursing. Her clinical experience was

gained in a hospital setting on a variety of units. Nursing specialties she became

171

familiar with over the 10 years she spent as a caregiver include internal
medicine, surgery, pediatrics, intensive care, obstetrics and emergency nursing.
She began a transition away from hands on nursing when she moved into a
position within the hospital doing utilization review (UR), and then over to the
HMO performing a similar function. She explains UR in the following way:

Doing UR you’re basically moving the patient, the member through
the hospital system as an in-patient. It’s an isolated part of their
care. It’s while they’re in the hospital that’s what you are...making
sure the appropriateness of the member’s stay, and you’re making
sure that they’re getting the appropriate care, the appropriate tests.
They’re not over utilizing tests or under utilizing tests.

When asked to comment on the difference between UR and CM, Fran
responds “a UR person gets them out of the hospital and a case manager keeps
them out of the hospital.”

Fran found the transition from giving care to UR more difﬁcult than
transitioning from UR to CM. That’s when she needed to shift to different focus
and begin to look at business aspects of health care.

The biggest transition from care...it’s the business world. It’s
learning to do memos and e-mails and you know, business
appropriate. It truly is. That was the biggest thing... because
you’re going from you know, staff nursing. And hospital nursing is
awfully; I don’t what the word is. I don’t want to say it’s crude, but
it’s at a base level, you know. You’re caring for people’s physical
needs. You’re helping them with their bowel movements. It’s a
different relationship. Whereas when you come into managed
care... it’s more of a professional situation. Way more
professional, I think.... You’re Ieaming the business world. If you
take a staff nurse who’s biggest concern is making sure the meds
are passed and the bed is made and the NS are hung to someone
to a position here you really need to produce a statistical report, it is
a big transition. You need to show outcome... you’re not really
judged on how the patient is doing, how the client is doing. You’re
really more judged on well how’d that report come out, your know.

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Are you showing that this has been effective? Did you collect

enough data? Are the numbers going down? The focus is not the

patient... I’m really speaking from the UR piece.”

After 2 years of UR, Fran moved into a CM position with the HMO. Her
motivation for this was “boredom.” She knew she had exhausted her
enthusiasm for providing hands on care, and felt that case management was the
logical next step. It not only afforded her contact with members (patients), but
allows her to develop longer term relationships that can have a signiﬁcant impact
on the healthcare they receive and as a consequence, their health status.

I truly like navigating someone through this hideous horrible

monstrosity called health care. This is the corniest of all. When

someone asked me. “Why did you go into managed care?” I said,

“You know why I went into managed care? I wanted to humanize

managed care.” And I mean that with all my heart. I really did. It

didn’t always happen, but I want to be able to hold someone’s hand

and help them through. Because it’s a damned maze, you know. It

is. I mean it’s a horrible maze. I don’t understand how people who

are physically or mentally compromised can make it through the

system. They don't they don’t make it through the system. I ﬁnd it

very rewarding to be able to help someone through.

Learning to function as a case manger was not difﬁcult for Fran. The
understanding of managed care she gained through her UR experience, and
exposure to case mangers both in the hospital setting and at the HMO provided a
good foundation. She found ample professional resources within the
organization to answer her questions, like the physicians and lawyers on staff, as
well as her coworkers. Fran also is an active member of the local case
management professional organization, which has made her aware of more CM

issues, strategies and practices.

Fran describes sources of role strain for her as legal aspects off

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Fran describes sources of role strain for her as legal aspects off healthcare
coverage (i.e. Medicare & Medicaid) as well as the bureaucracy she encounters
when she judges that a member requires something out of the ordinary,
something that isn’t routinely covered by HMO beneﬁts. When faced with a
conﬂict between what she feels the member really needs and what is expected of
her in terms of procedure, she conﬁdently states

I know it sounds kind of corny to say, but it’s the truth. Ultimately,

what is going to help that person the most? I might have to also

follow my major procedures. I try to do that too. But if I have to

choose between following the procedure and doing what’s best for

the member, and those are my only two choices, I’m going to do

what’s best for the member.... it’s not that much of a struggle for

me because I already know the answer I’m going to pick. But it may

be for someone whose new to, you know, the employer. Or it’s not

much of a struggle. But yes, I mean yes it is. I mean its conﬂict.

It’s controversy.

F ran’s professional identity is closely aligned with the role of NCM. She
acknowledges that her care giving background provided her with an
understanding of the patient’s perspective, what they go through, what they try
not to show, what will help them to understand. She feels that her role carries a
tremendous responsibility.

In the hospital what you did then impacted the person directly. But
as a case manager I think what you’re doing is important because
you’re impacting the person for not just those three days... It’s

different. You’re the case manager. That’s who they’re counting
on for the whole time, not just that 8 hours.

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GINGER

Ginger is a 53-year-old nurse who does telephonic CM for a workers’
compensation insurance carrier. She has been in this role, with this employer for
1 year. She works with Irene, Belinda, and Ann. She explains her role in the
following way.

Well, a lot of times I just don’t feel like a lot of what I do is nursing
decisions. It seems to be that anyone could be trained for what I do,
that doesn’t have a medical background...| mean there are ‘
certainly times when my nursing knowledge has an impact. But I
think for the most part it seems like it’s basically a lot of things that
the claim adjusters did before as far as authorizations, approvals,
procedures, what have you, following doctor’s visits, that could be
done by someone more trained to do it...| thought that if I left the
hospital that I’d go into a teaching position type thing, you know.
That’s kind of what I liked to do. ...But I guess that this is probably
the closest to that if I do see anything really positive about it.... and
| feel like I can at least impact that way in doing like pre-op and
post-operative type teaching with these people..Also just general
education with them as far as work comp and what’s expected of
them as far as their efforts and their treatment program. And pretty
much I think most of them are really responsive to, you know, once
you can set up a connection with them.

Ginger holds a Bachelor of Science degree in Nursing. Her clinical
background spans 30 years of hospital nursing, the last 24 of which were in the
emergency room. She had some limited supervisory experience but found that
she much preferred ﬁrst hand patient care responsibilities. She also became
involved as an instructor in various training programs in the hospital associated
with critical and emergency care, which she enjoyed. Her motivation to leave her
role as a caregiver had more to do with dissatisfaction about changes in the

environment than with dissatisfaction with the role of caregiver.

175

Within the last, I’d say, three years it just got so stressful. I really
liked what I was doing and I felt like I was good at it. And I really
did enjoy the hospital setting and I miss that. I miss that acute care
aspect of it. I miss the patient contact. But they started cross
training people and eliminating positions. Like ﬁrst it was the lab
techs, and then the nurses did all the blood drawing. Then the next
thing was the EKG tech, and slowly but surely adding more and
more patient load on you and additional responsibilities. I was
working three 12-hour shifts a week on the day shift 7am to 7pm.
And there was many, many times when you just weren’t getting
your breaks and what have you... just the situation involved a
position where you just could not leave. I mean you were tied to
that and if you didn’t have a relief, you know, that was it. So it just
became more and more stressful to me not taking breaks and
whatever and that’s basically why I got stressed out, not because I
got fed up with the job itself. I really liked the emergency nursing. I
probably would still be at the hospital if it weren’t for that.

She had a friend who had recently accepted a position as an NCM at the
insurance company. Looking for an alternative, Ginger asked her friend to
contact her when another position became available. When one opened up
Ginger applied and was hired.

Ginger describes her orientation to the role of case manager as being
presented with a signiﬁcant amount of “dry material.” They provided some
formal programs and some reference materials.

They provided an in-service when I ﬁrst started. Basically I felt I
was left alone a lot to just learn on my own. I mean they provided
the manuals and what have you, but I felt I learned more doing the
hands on...on the computer and following through on what was
presented to me in the manuals and during orientation. Until I
actually got my own caseload and had to deal with what was
expected, I think that’s when I ﬁnally started learning and had more
questions.

Ginger had anticipated a confrontational experience with the claimants,

but found that not to be the case for the most part. She ﬁnds satisfaction in

176

Ieaming more about the long-term treatment course and recovery from injuries.
This view of the healthcare system was not apparent from the emergency room.
She enjoys feeling inﬂuential in positive outcomes - like when an injured worker
has a good experience with a physician that she has recommended.

Her sources of role strain are many. In addition to feeling as though this
role does not present her with sufﬁcient opportunities to utilize her expertise, she
is uncomfortable with the focus on cost containment, quality measures
associated with documentation, and working with adjusters who seem resentful
of a nurse’s involvement in their ﬁles. Like Ann, Ginger had to learn to set
priorities and organize her work differently than in an emergency situation. She
needed to acclimate herself to working a caseload through a diary system, and
reconcile to the fact that there is no complimentary shift to back her up as there
was in the hospital.

When asked if she thinks the role of case manager in any way
compromises her identity as a nurse Ginger replies “-I don’t think it compromises,
I wouldn’t say because it’s just a different phase of ...nursing practice for me...l
do feel like I’m using my nursing, but not to the extent of my expertise -- to what I
was working in the last few years, of course.

Ginger thinks she will stay in this role for another 4 years or so, at which

time she is contemplating “semi retirement.”

177

HANNAH

Hannah is 41 years old. She holds a BSN and is currently completing a
Master's degree in exercise science. For the past year and a half she has
worked as an NCM for a CM vendor. She does onsite CM for a variety of
insurance carriers, the majority of which are workers’ compensation carriers, but
also has cases from automobile insurance and short-term disability carriers. She
describes her role as ”a coordinator of care." She explains that the most
important aspect of her current role is to:

...keep the communication going because that’s always a problem
....between the physician and the patient and the worker's comp
carrier. I think that’s a big failing in the health care industry is
communication... You make sure that when you go see that new
physician he’s got all the information he needs plus you verbally tell
him what has gone on in the case. So I think the communication
feels a little bit better. And then the physician’s focus is not return
to work... all you have to do sometimes is sit there and they know
why you’re there so they’ll address that issue where if you’re not
there it’s not addressed and the patient isn’t going to always
address...that issue.

Prior to assuming the role of NCM, Hannah provided nursing care in a
hospital setting for 4 years on orthopedic surgical and oncology units. Following
that she worked in home care for 10 years. She relates that her transition from
the hospital to home care was far more difﬁcult than her transition from home
care to case management.

The transition from a hospital to home care is difﬁcult because

you’ve got to be very independent you’ve got to make decisions on

your feet you don’t have people around you. That took me a while.

I think I was younger at the time, didn’t have a lot of experience.

But by the end of my experience, I think I was very good at it and

you learn to be very independent make decisions know when to call
physicians. And you manage a caseload. I mean this one person

178

and all their problems is up to you, how often you see them, that
type of thing.

Describing her experience of transition from Home care to CM she relates:

That was easy. It was actually easy. The reason it was easy was

probably because I was used to working with one person. I mean

had I gone from the hospital to home care. That’s a little more

difﬁcult. But going from home care into this, ....you had different

cases that you managed and needed to make phone calls on. And

I mean it was something that’s always in your mind. These are the

people you’re responsible for so that aspect of it wasn’t easy

learning. How the [CM] process [works], that was more difﬁcult.

Hannah sought out employment alternative to home care because of
Medicare regulation changes that signiﬁcantly impacted home care and because
it was becoming what she perceived as "too political". She heard about CM from
a former coworker who had moved into that role. She thought it would offer her
the ﬂexibility of working in the ﬁeld as well as opportunities to interact with
patients and physicians. She had some notion of the possible conﬂicts that may
occur with workers’ compensation cases but has found the majority of her
interactions with claimants to be not as confrontational as she had imagined.

Hannah describes her opportunities for learning CM much less structured
than when she practiced in the hospital or home care. She states

It wasn’t really a formal training. It was more you came in they

gave you cases and you just asked questions. And that could have

been partly my personality, because I think I picked it up pretty

quick as my boss said. So it was more a matter of working the

cases and constantly going to them to ask questions. I did go

there. ltook over for another nurse that was leaving. So I went

outwith her I think it was 2 or 3 visits and then I think ...I just then
took a caseload and started working it.

179

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The main sources of satisfaction in her role as an NCM for Hannah are the
job conditions of ﬂexible hours, working in the ﬁeld and being recognized and
respected for her contributions.

I think in some ways you get more respect in that for your

knowledge, especially with an adjuster who doesn’t really

understand the medical aspect. I think it’s very rewarding when

you get someone back to work that actually has had an injury and

is grateful that you have helped them and realizes that you

deﬁnitely have added to the process.

The stressors she has encountered include dealing with malingers or
being assigned to a claim when the adjuster and claimant don't get along. Also,
when she feels that she can no longer impact the outcome of a case, and the
patient is not progressing.

She appears to have accepted most of the challenges of this new role in

stride. She is not sure where she will go from here career wise. She indicates

that she’ll cross that bridge when the desire or opportunity presents itself.

IRENE

Irene is a 56-year-old NCM who has been employed by a worker's
compensation insurance carrier for three years. In this setting she practices
telephonic case management. She explains her role in following way: “I pretty
much take a case from beginning to end, make sure that the injured workers are
getting the proper care in the shortest amount of time." She further adds, “I'm a
mentor for the adjusters ...[I] answer medical questions, answer what drugs do

what, why patients might be on certain drugs, a question and answer person."

180

She gained 8 years of experience as a caregiver on a medical unit in a
hospital early in her career. The majority of her nursing experience, however
was 13 years in a pediatric clinic where she assisted physicians with medical
examinations and procedures and was accessible for phone consultation with
parents who had questions or concerns about their children’s' health.
Signiﬁcantly invested in her identity as a pediatric nurse, Irene continues to work
weekend shifts for the pediatric clinic. This keeps her connected to what she
most enjoys doing.

Her experience of transition from care giver to case manager was affected
by the fact that she felt she had to move away from a role that she loved and
valued to one that served to satisfy only her ﬁnancial needs. Irene describes her
transition experience as "terrible...l hated it”

It was very emotional for me. I absolutely loved my clinic and for
socio-economic reasons I had to. I was divorced after 30 years and I
had no pension or any of those kinds of things available to me so I
knew I had to do something else that was going to take me into my
retirement. So it was a very, very difﬁcult thing for me to give up my
pediatrics and go into case management. I like it now. I don’t love it. I
like it. I think I’m pretty good at it. I’ve gotten a conﬁdence and that
kind of thing. I’ve gotten a raise every year but I’m here because I
have to be.

I was also older and l was terriﬁed that I wouldn’t know what to do. I
did have some training but not what I would have felt that I needed. I
did feel, on the other hand, they don’t often hire pediatric nurses to do

case management and I sort of accepted that. I sold myself that I
could do this job even though they had other ofﬁces say, " why

would you hire pediatric nurses for case management?" I think a lot
of our skills as pediatric nurses have been a more positive thing than
they anticipated.

I think any time you start something new, the older you get...you think
you know this. Well, plus I felt I knew pediatrics very well and I didn’t

181

need this in my life and I didn’t want to start over being the bottom. . ..
We’ve had some young nurses go through that [have said] "This was
great. Now I’m done with this. I’m on to the next thing." I’m in a
different place. Where maybe if I’d been younger, I might not have
been as uncomfortable with the transition. But that’s just my own, and
you will notice that so many of the nurses who have made this
transition we are all middle aged. And everybody has had just as
much trouble and just as much stress and I kept saying "You girls
worked in the ER for God’s sake. What is the matter with you? Talk
about pressure. What are you getting upset about?" But it’s that not
knowing; the feeling that you’re at the bottom... when you felt like you
knew what you were doing.

An element of the case management context that she ﬁnds unfavorable is
having to deal with claimants who lie in order to receive workers' compensation
beneﬁts, even though she feels she has a good working relationship with most of
the claimants whose cases she manages.

Another element that perplexes her is being subject to a legal system that
provides what she perceives as incentives for deceitful behavior. Working with
adjusters at times causes additional stress when they discount her input about
what is needed medically for a claimant, or simply when they are jaded in terms
of trust or respect for the injured party or medical providers.

A lot of the adjusters don’t really want us in their face. They really

don’t want to hear what we have to say. They resent sometimes

that we’re getting involved in their ﬁle when they would rather do it

themselves... Sometimes you’re kind of ﬁghting, you know. They

want to close [the ﬁle], or they want to dispute [the claim]. You say

[to them] "This is very possible that this [injury or complication]

could happen.

Irene describes her source of job satisfaction as being able to arrange for

the appropriate healthcare or work accommodations for injured workers and

therefore impacting their recovery and return to work. She admits that this role

182

has provided her with opportunities to learn a lot about other medical specialties,
about the insurance ﬁeld and the legal nuances of workers' compensation -
things that she was not even aware of prior to assuming this role. She feels she
has perhaps more autonomy here as a case manager than in her role at the
pediatric clinic. She explains, " You pretty much set it up and this is how you
organize it. You set it up, and plan it through, and hope that it goes... you’re
deﬁnitely on your own more.”

In terms of learning how to function as a CM, Irene explains that there is
some formal training in the policies and procedures of the organization she works
for. Her supervisor, who is also a nurse, oversees the workﬁow and work
products of the case managers. This supervisor is available for questions and
offers feedback when asked. Irene owes much of her learning CM to self-
directed research through asking questions, networking with coworkers and the
healthcare providers and vendors that she interacts with in the course of her
workday. She also attends meetings of a local professional organization of case
managers, where she is able to get updates on current medical and legal issues
and alternate perspectives on case management resources, strategies and
practices.

Irene relates that her nursing education and her previous experience in
the hospital and at the pediatric clinic contributed to her CM skill set by providing
basic knowledge of illness and healthcare. She attributes her organization skills
and sensitivity to need to her foundational education and work experience as well

as her life experience in raising a family.

183

With regard to her preparation for assuming and functioning in the role of
NCM, Irene felt least prepared to act as a broker of healthcare services. VWthout
a working knowledge of local providers or medical specialties outside of
pediatrics, she found the task of making referrals to medical specialists or
monitoring medical treatment rather intimidating. She also felt ill at ease with the
use of a PC.

Although she feels she has gained considerable conﬁdence through
experiential Ieaming on the job, Irene remains reluctant to accommodate her
professional identity toward that of a case manager.

I think when you tell people you are a case manager in an

insurance company they think you know it’s no big deal. I don’t

think people have a lot of respect for case management I think

they think you just run around and try to out money you know I

really do and if you say you’re a pediatric nurse people go oh wow

that’s so good oh my little grand baby just fell down the stairs

yesterday you know there’s deﬁnitely a difference for a hospital

nurse. Yes I can honestly say that I would have no doubt about.

People say what are you doing now. Oh. You know it’s just not the
same.

JUDY

Judy is a 43-year-old nurse who is currently “in between” jobs with case
management companies. For the past 15 months she worked as an onsite
NCM, contracting with automobile and workers’ compensation insurance carriers.
She will be starting to work with a different CM company within the month. Judy
struggled with understanding her role as an NCM, taking cues from multiple

sources.

184

I didn’t know what they wanted exactly. . .. What did these adjusters
really want you to do? ...My mentor case manager projected this
idea that I was supposed to really be saving money...for (the
insurance companies). You know, “hound on the fact that you’re
saving money for them in this area and that area yada, yada, yada.
Really, just let them know how great you are, and how good you’re
going to get things done so quickly and yada, yada, yada.’ And
then the doctors, he’s really guiding what’s going to go on so you’re
just, it was like, “ok, ok.

I think that there is this balance that you have to ﬁnd in case
management, how to get the best care most efﬁciently. And I think
the longer you ‘re in it, you become more comfortable making those
decisions and understanding that what you’re doing is that way it is
quality and it is efﬁcient. But when you’re ﬁrst starting you’re not
quite sure.

Having completed an Associate Degree in Nursing (ADN), Judy is currently
in an ADN- to- MSN (Master of Science in Nursing) program in nursing
administration. Her clinical background consists of 1 and ‘/2 years in a hospital
on a general medical surgical unit and 7 and V2 years in home care. Her home
care experience included a supervisory role for the last year. In addition her
nursing experience, Judy did clerical work, was a dispatcher in a sheriff’s ofﬁce
and assisted her husband in running a bakery.

She describes her transition experience to CM as a mixture of ease and
difﬁculty. On the one hand, her clinical knowledge and skills enabled her to
understand what patients needed, but on the other hand she struggled with a
pressure she felt to appear competent to the insurance companies in order to
realize more case assignments.

The transition was difﬁcult in trying to interpret no- fault and
worker’s comp guidelines. That part was difﬁcult. But one part that

was very similar was, you know, assessing the people, interviewing
people, developing a plan, setting goals. That was similar. So

185

what was hard is there was this big fear of making adjusters think
you were competent right off the bat so that they would refer you
more cases. Well you’re not competent right off the bat, so how to
accomplish that feat was just to me, you know, I didn’t know how to
pretend like I knew what I was doing. And so I would really limit
my conversations with adjusters so they wouldn’t get the hint that I
really didn’t know what I was doing. Which I think was a mistake
because then I couldn’t pull enough information on what maybe
they did want. And so there was always this ﬁne line of pretend like
you really are this you know great case manager but then try and
ﬁgure out what that means, because you don’t know.

Judy entered the ﬁeld of case management as an alternative to home
care, which was becoming, in her perception, too regulated. In the course of her
home care responsibilities, she had interacted with an NCM who was working
with the insurance company involved with the case In conversations, she
Ieamed more about the NCM role and found out that this nurse would soon be
leaving and that her employer would be looking for a replacement.

She started to tell me about what her job was like and what she did

and it just sounded like perfect, exactly what I was looking for - an

ability to use your education and you know connect with so many

different professionals. That is really interesting to me, the

attorneys, the physicians, and I just think it’s really cool....So I just

kind of ﬁgured because I had supervisory experience and home

care experience, I ﬁgured I might have a good shot at getting in

there and I did. I took her spot when she left, which was perfect

...the timing, you know. I don’t know if I wouldn’t have had that

connection I would never be in this case management, never. If

she wouldn’t have called me about that one position, I would never

have made this turn.

Judy found that the resources for learning CM were sparse, and that she
depended upon trial and error and ﬁnding answers to her questions in the course
of case assignments. The training and support she did receive from her employer

did not meet her needs as a novice.

186

They had a couple of meetings in this 15 months. And I found them
to be extremely irrelevant and very poorly presented, very not
helpful for someone at my level. They were geared more towards
people that maybe had been in case management. Talking about
maybe speciﬁc guidelines in a workers comp thing, while I’m trying
to understand the broad basic guidelines. Don’t go into one you
know obscure element of these things and hound on that when I
don’t know even understand the bigger picture. 80 that was really
frustrating, very frustrating.

She explained also that the nursing program that she is currently enrolled in does
not provide any course work or practicum in case management.

Judy’s sources of job satisfaction include being able to streamline the
recovery process for legitimate claimants as well assisting the adjusters weed out
questionable claims.

I think it’s really rewarding when you can make things easier for the

client. You do a lot of legwork, answer their questions, anticipate

what they’re going to need, and just facilitate their recovery. That’s

rewarding to me. And I kind of like sometimes when you do get

those...people that are playing games with the insurance company.

I like to kind of let the adjuster know other pieces of information...

When you do that initial assessment you can glean little statements

from them that are just really telling. I mean they are very telling

and I know that if the adjuster wouldn’t have called a case manager

in the adjuster wouldn’t know those little statements that are very

helpful to get an overall idea of whether the claimant’s playing a

game or not.
Like other participants in this study, Judy ﬁnds dealing with secondary gain
issues associated with some workers compensation claims disturbing. Also, the
mistrust she has encountered from claimants who view her as a representing the
interests of the insurance company in lieu of theirs is surprising. This is an issue

she had not encountered prior to taking on the role of NCM. Perhaps the more

disturbing, however, was the pressure she felt from her previous employer to

187

_ . _ 44““;

..5‘_u-T .-
. I

market her services to adjusters, when she was unsure of her ability to meet their
expectations.

Despite her frustrations in Ieaming the role and marketing her services,
Judy ﬁnds the Opportunities to learn in case management worth the struggle.

I want to expand my knowledge in it. I want to understand the
legal aspects. There’s a lot of it that I ﬁnd really interesting and
challenging, and I like that in a career. There’s, you know, the
physician contact, and Ieaming all about these, you know, different
injuries...l just ﬁnd it all fascinating because of the variety. I guess
I can see myself doing this. I would like to do this for say the next
ﬁve years for sure. And then where I’ll go from there I’m not sure I
don’t know. But I would like to become I guess more comfortable in
case management.

KAREN

Karen is a 44-year-old nurse who has been working as a telephonic case
manager for a health maintenance organization (HMO) for about two years. She
describes her role in the following way:

With managed care you have the primary care [physicians’]
support, you have home care you can call on to allow these people
to learn to take care of themselves better. Maybe a diabetic
doesn’t check their blood sugar, [I can arrange for home care] to
teach them how to do that, to provide a glucometer for them,
to...provide home care so they can Ieam how to do that. Then
maybe we won’t have tons of diabetics uncontrolled. And one big
thing right now is our morbidly obese people. You know if we can
get people when they’re 200 lbs. instead of 500 lbs. you have a
better chance of helping them...[like] calling the primary care
people- the doctors- and saying “This looks like a weight
management issue. Can I help you? Are you doing anything about
it? Have you talked to the member?”

Karen was originally trained as nurse in a hospital-based diploma program

and the completed a Bachelor of Science degree in nursing seven years later.

188

Her care giving experience was obtained in the hospital and home care setting
for the ﬁrst 15 years of her career. The following seven years were spent in
discharge planning and utilization review at the hospital. She feels that case
management positions in hospitals today are evolved from those two functions
and ﬁnds that her experience in these two areas of managed care has helped her
conﬁdence in assuming the role of case manger with the HMO.

Her motivation to join the case management staff at the HMO came from
dissatisfaction with the hospital setting.

I had had it with hospitals. I want to do something different... I’m

weighing sanity verses less pay. But a different a different outlook,

a different something to do...[ln the] hospital setting I was putting in

10 to 12 hours on my feet all day, no lunch and leaving the hospital

exhausted...We were doing discharge planning and utilization

review so we were reviewing charts. We were on our feet all day.

There was nowhere to sit to review ...you could review lots of

different units or you work one unit. Now I’ve Ieamed there just

keeping people on one unit, which I think is a much smarter thing to

do. But at that time we weren’t. In addition to doing that, you

would do a discharge plan so you were trying to get people out the

door at the same time. And I just wanted a change. I want to do

something different. I really felt like I was going to be committed if I

didn’t do something different.

Karen’s source of job satisfaction is her ability to help members maintain
their health. She likes the proactive, preventative aspect of her role. She also
likes the opportunities she has to learn about things she had never even
considered. She is currently doing a self-study program on managed care
concepts in order to earn a certiﬁcation that will enhance her standing and salary

in her department. She ﬁnds her present situation a very supportive learning

environment.

189

There’s a whole body of knowledge within managed care that I
didn’t even know existed, like point of service, beneﬁt packages,
how a primary care physician works differently than a specialist,
works differently than a plan medical director, what plan medical
groups are. All these were Greek to me. I mean we had a 6-month
orientation just to stay here and I feel like I needed a year of
orientation. And it’s only been in the past probably 6 months that I
feel kind of comfortable in some areas. And I’m still learning,
especially in the case management aspect. It’s growing and
changing and things are being added and we’re all learning
together. That’s why I kind of like about my coworkers, that we’re all
in this boat together leaning. And my managers seem to
understand that.

There are sources of role strain for Karen as well. Dealing with the ﬁnancial side
of healthcare continues to be difﬁcult.

I guess being raised in a hospital and at home care that’s not a
concern. I mean maybe it is now, and it wasn’t when I was doing
bedside nursing. I mean if [patients] needed a dressing, we did a
dressing. I mean if they needed medication they got it. If the
doctor ordered something, he got it... Financial concerns still kind
of make me uncomfortable. l’m dealing better with them. And well
you work [an HMO] and that is an issue. And if ﬁnances aren’t
contained then people don’t have jobs. And you know you really
see that there are people that abuse the system.

With regard to her professional identity, Karen offers:

A nurse giving care is very important. A nurse doing case
management is also important. It’s two ends of the spectrum, I
guess. I wouldn’t say one’s better or not better than the other
one... I did bedside nursing. As much as I enjoyed helping
somebody out of bed or you know all the basic nursing stuff, I’m
enjoying helping people in this way as much as I did.... I don’t think
I’ll ever not feel like a nurse I’d be doing different kinds of nursing.

190

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