Certified Case Managers’ Lived Experiences in Hospital Networks: A Phenomenological
Inquiry
A dissertation presented to
the faculty of
The Patton College of Education of Ohio University
In partial fulfillment
of requirements for the degree
Doctor of Philosophy
Mary I. Moffat
December 2017
© 2017 Mary I. Moffat. All Rights Reserved.
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This dissertation titled
Certified Case Managers’ Lived Experiences in Hospital Networks: A Phenomenological
Inquiry
by
MARY I. MOFFAT
has been approved for
the Department of Teacher Education
and The Patton College of Education by
Ginger Weade
Professor of Teacher Education
Renée A. Middleton
Dean, The Patton College of Education 3
Abstract
MOFFAT, MARY I., Ph.D., December 2017, Curriculum and Instruction
Certified Case Managers’ Lived Experiences in Hospital Networks: A Phenomenological
Inquiry
Director of Dissertation: Ginger Weade
The purpose of this qualitative phenomenological study was to understand the shared lived experience of registered nurses certified in case management (RN-CCM) employed in hospital networks. For this project, the phenomena of problem-solving conflicts are generally defined as the experience of work-related conflicts, meaning- making given to phenomena, and strategies to reconcile unsatisfying outcomes as advocate. Phenomenology theory is most applicable because the lived experience can contribute to the depth and breadth of understanding of ethical and practical conflicts occurring in health care delivery. Participants were interviewed about their work and self- care interests. In the context of health care, a relationship emerged between outstanding conflict themes and problem-solving skills. Ethical principles established in codes of conduct contribute to perceptions of dilemmas leading to conflicts: benevolence, nonmaleficence, autonomy, and justice. Personal attributes of empathy and emotional intelligence contribute in collaboration skills. Self-care actions change lives by reducing internalized responses to conflict and reinforce personal identify and values. The meaning-making of certification is placed in the self-care theme because it is experienced as a validation of professional expertise, networking, and accruing required CEUs. Three conflict themes emerged in the interviews: change, task-relation, and caring. Of these 4 three themes, conflict of caring presents a unique and meaningful engagement for RN-
CCMs in complex health-care systems today. The data informs the reader on the perception and experience of conflicts and self-care for seasoned RN-CCM and may be of interest for further study about experiences and coping skills of those who collaborate on patient care within healthcare networks.
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Dedication
In gratitude for ethical and empathetic caretakers and educators who are inspired to
mitigate the suffering of others. 6
Acknowledgments
This project survived because of the diligence and mentoring of Drs. Ginger
Weade, Adah Ward-Randolph, and Dwan Robinson; the gracious assistance of my peers; and the infinite wisdom-keepers of our natural world, guiding us through cycles of a conscious life if we humbly abide. 7
Table of Contents
Page
Abstract ...... 3 Dedication ...... 5 Acknowledgments ...... 6 List of Tables ...... 10 List of Figures ...... 11 Chapter One: Introduction ...... 12 Significance of the Study ...... 16 Research Questions ...... 17 Methodology ...... 18 Limitations ...... 19 Delimitations ...... 20 Research Ethics ...... 21 Definitions ...... 21 Accountable Care Organization (ACO)...... 21 Acute care...... 22 Acute-care hospital...... 22 Advocate...... 22 Case manager...... 22 Conflict phenomena for RN-CCM...... 23 Conflict of interest...... 23 Contractualism...... 23 Deontology...... 23 Emotional intelligence...... 23 Ethic...... 23 Interqual...... 24 Summary ...... 24 Chapter Two: Literature Review ...... 26 8
Ethics, Codes of Conduct, Empathy, and Emotional Intelligence ...... 28 Ethics ...... 29 Codes of conduct...... 37 Empathy...... 38 Emotional Intelligence and Empathic Maturity...... 40 Problem-Solving Process, Ethical vs. Practical Conflicts, and Moral Distress ...... 45 Problem solving ...... 45 Ethical vs. practical conflicts ...... 47 Moral distress...... 47 Historical Health Care Context and Case Management Duty ...... 51 How social governance begat professional case management advocacy...... 51 Standards of practice and codes of conduct ...... 58 RN-CCM scope of practice ...... 60 Summary ...... 63 Chapter Three: Methodology ...... 65 Historical Evolution of Phenomenology Philosophy ...... 65 Research Design ...... 67 Interpretive Phenomenological Methodology ...... 68 Tools of Research ...... 71 Data Collection ...... 75 Data Analysis ...... 76 Self as Researcher: Disclosure ...... 80 Chapter Four: Those Who Care: Reflections of RN-CCMs ...... 82 Finding RN-CCMs to Participate...... 82 Being an RN-CCM: Attributes, Self-Care, and Work Interactions ...... 83 Attributes ...... 83 Self-care ...... 86 Work interactions ...... 87 RN-CCMs Working Biographies: How We See What We Do ...... 88 Ben Harris (BH): Inspiring advocacy by expecting better patient outcomes ...... 88 9
Colin Marble (CM): Advocating for better care one act at a time ...... 96 Helen Roberts (HR): Being compassionate for other’s imperfections ...... 104 Maria Jay (MJ): Using infinite patience resolving infinite problems...... 109 Kelly Freer (KF): Knowing why and how to fix a problem...... 116 Proactive Nurse (PN): Mentoring others to lead toward healthy possibilities .....121 Jeanne Good (JG): Identifying potential high-risk patients in computer reports. 132 Marie Crumb (MC): “Seeing” with a mind’s eye using only the telephone...... 143 Summary ...... 153 Chapter Five: Emergent Themes ...... 156 Conflict: What It Means and Why It Matters ...... 158 Conflict of Change ...... 160 Conflict of Tasks and Relations ...... 168 Conflict of Caring: Scope, Advocacy, Attributes, Moral Distress, and Self-Care ....179 Attributes ...... 182 Moral distress: A risk to RN-CCMs experiencing conflicts of care...... 194 Case Management certification as self-care ...... 195 Summary of Emergent Themes ...... 199 Discussion and Implications ...... 200 Implications and application of inquiry ...... 207 References ...... 210 Appendix A: IRB Documents ...... 221 Appendix B: Interview Questions ...... 225
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List of Tables
Page
Table 2.1 Relationship of Moral Principles, Rules, and Action to Corresponding Virtues ...... 30
Table 2.2 Empathy Categories Compared Between Goleman and Olsen ...... 44
Table 4.1 Demographic and Professional Experience Characteristics of Certified Nurse Case Manager Participants in Order of Presentation ...... 85
Table 5.1 Emergent Themes of Conflict for RN-CCMs ...... 157
Table 5.2 Phenomena of Conflict, Ethical Principle, Action, and Examples ...... 192
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List of Figures
Page
Figure 2.1. Relationship of society’s moral virtues and values informing ethics in RN- CCM Codes of Conduct ...... 31
Figure 2.2. Autonomy principle of the virtue of respectfulness informs actions of forgiveness ...... 33
Figure 2.3. Non-maleficence principle of the virtue of doing no harm informs actions of generosity ...... 34
Figure 2.4 Justice principle of the virtue of justice or fairness informs acts of kindness ...... 35
Figure 2.5. Beneficence principle is the virtue of benevolence informs acts of compassion ...... 36
Figure 2.6. The levels of empathic maturity...... 44
Figure 5.1. Relationship of principles, conflicts of change, task-relationship, and caring ...... 191
Figure 5.2. Problem-solving contributing factors in health-care context...... 193
Figure 5.3. RN-CCM matured attributes used when collaborating and problem-solving ...... 194
Figure 5.4. Ethical dynamics of Figure 2.1 refined...... 201
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Chapter One: Introduction
The registered nurse certified case manager (RN-CCM) makes essential and unique contributions in health care today. Little is known to others about the skills and duties of this job. An RN-CCM prevents gridlock reimbursement protocols, conflicts of interest, and decision-making that includes patient rights of autonomy and informed choices. The role of the RN-CCM has evolved because of a perceived need to unify assessment, collaboration, problem-solving, and resolution of inevitable conflicts within a system comprised of vested interests. The goal of this research is to discover the RN-
CCM’s lived experiences of unavoidable and often unresolvable conflicts and dilemmas within hospital networks.
Historically case managers have required assessment and collaboration skills.
Today the hospital case manager role includes collaborating with health-care professionals and patients to resolve complex dilemmas among different interests and motivations within the health-care system. Dilemmas result from competing or conflicting interests that define moral actions. Institutions (employers), clinical services, and personal values contribute to conflicts experienced by RN-CCMs. First, hospital administrators have an obligation to honor (a) network contracts which can limit access to more appropriate nonnetwork providers, (b) maximize reimbursement for high-cost services, and (c) adhere to government compliance and insurance regulations to ensure reimbursement. Second, clinical teams with whom the RN-CCM interact are held to performance metrics of high-risk (cost) populations under the manager’s care, such as diabetes and cancer. This is called pay for performance and replaces fee for service 13 reimbursement structures. Third, professional staff are entrusted with adherence to efficient and ethically sound transitions of care. Staff includes groups of physicians, administrators, and licensed caregivers. These groups interpret bioethical principles and moral actions differently. Therefore, administrators of hospitals or insurance company protocols influence and may determine resource utilization, fiscal parameters or limitations of interventions. How the RN-CCM’s experience collaborating among these groups within a variety of hospital settings contributes to an understanding of the evolving complexity in today’s health care processes.
Complex collaboration in health care decision-making requires ethical and practical problem-solving skills supported by codes of conduct. Conflicting views of what practice is moral is common (Beauchamp & Childress, 2001). “Ethical theories attempt to explain and to argue how ethical conduct is defined. These ethical theories ubiquitously support the principles of ethical practice.…Principles are embedded into codes of conduct defining ‘moral’ action” (Banja, 2008, p. 595). “Ethics offer a way of examining moral life” (Edge & Groves, 1999, p. 40). Different groups in health care may hold to ubiquitous social principles and ethical virtues relevant to the health care industry in general and yet define moral actions or practices and behaviors differently. Resulting conflicts are influenced by divergent views of ethically virtuous actions.
The qualities of a moral life are based on theoretical frameworks informing virtuous actions. Beauchamp and Childress (2001) identify five central ethically virtuous actions for health-care professionals: compassion, discernment, trustworthiness, integrity, and consciousness (pp. 32-38). In 2008 Banja identified and defined four theoretical 14 models applicable to a divergent variety of ethical actions and implicitly contributing to ethical dilemmas as deontologism, contractualism, virtue, and utilitarianism (pp. 597-
598). Beauchamp and Childress refer to an emerging ethics of caring theory to combine the moral integrity of professional codes of conduct with the caretaker’s capacity “for discretionary and contextual judgement” (Beauchamp & Childress, 2013, p. 36). These codes and personal judgement help in prioritizing patient advocacy and autonomy.
Different groups can believe in their moral integrity and still experience conflicts with other health-care providers who have a different set of priorities.
Perceptions of moral actions can collide with competing concepts of virtues and qualities of a moral life (Beauchamp & Childress, 2001). Codes of conduct are guidelines for managing collaboration when these dilemmas surface. Different views and potential conflicts of interest are determined by one’s view of moral actions. Conflicts based on moral actions among stakeholders in hospital networks provoke dilemmas over cost of care, social hierarchies dominating decision-making, and advocacy of patient preferences.
An example is the ethical conflict based on distributive justice: Why do certain people get transplants or futile oncology interventions? This type of dilemma creates conflict based on perception of moral actions and virtues: Solutions to conflicts can be counter to one’s perceptions of what is right or just.
Competent navigation of routine health care conflicts requires advanced practice skills including adherence to professional codes of conduct, empathic maturity, and critical thinking based on years of interactions with others. In addition to the personal attributes mentioned, codes of conduct inform RN-CCMs in ethical decision-making 15 related to patient welfare (Cesta & Tahan, 2003). Personally meaningful activities also help accept outcomes perceived as unsatisfying. Established case management codes of conduct validate and guide the RN-CCM’s course of action “by which [case managers] must be held accountable” (CSMA, 2010, p. 2). Seasoned RN-CCM attributes and perceptions evolve with repeated exposure to outcomes of conflicts; codes of conduct are the guidelines to moral practice.
The purpose of this research is to capture mature RN-CCMs’ phenomena of conflict and the meaning of those experiences within the context of the hospital system and health care in general. RN-CCM skills are evident in anticipating, mitigating, and— when possible—resolving ethical and practical conflicts. RN-CCM moral actions are evident when anticipating and appropriately articulating the “significance of potential roadblocks to successful outcomes for patients” (Treiger & Fink, 2016, p. 236). Skill in overcoming roadblocks evolves over time based on personal attributes, employment histories, and exposure to problem-solving.
Case managers may experience conflicts among ethical codes of conduct. One study observed how new RN case managers responded to the role’s unique scope of ethical dilemmas in hospital settings (O’Donnell, 2003). This inquiry, however, departs from the earlier study by examining the lived experiences of seasoned certified RN-
CCM’s. This qualitative study of how RN-CCMs in hospital settings experience ethical and practical conflicts in patient care can provide a deeper understanding of RN-CCMs’ decision-making processes when addressing ethical and practical conflicts in hospitals.
The knowledge garnered from this research will inform a curriculum provided to support 16
RN-CCMs in their ability to advocate successfully for patient care within social structures.
Significance of the Study
Significance of this research is not to modify existing social structures and hierarchies. This research is significant as an exercise of discovery about the perceptions of RN-CCMs as they attend to daily responsibilities. RN-CCMs prioritize options and actions in a hierarchical system. Medical ethics are unique and challenging when considering the influence of inequities in power and authority (Beauchamp & Childress,
2001; Edge and Groves, 1999; Mills & Spencer, 2005; Ramos, 2015). Ubiquitous conflicts and dilemmas are experienced differently and implications of outcomes vary.
The phenomenological framework is appropriate and rigorous to study this topic (Reason
& Rigor, 2017, p. 5) because perceptions of phenomena are based on (a) the scope of practice (influenced by employment variables and historical context of the role), (b) established expertise informing the problem-solving process, (c) the meaning assigned to the conflict experienced, and (d) the volunteered disclosure of activities mitigating the impact of dissonant accumulated outcomes of conflict. This is significant work informing the overarching mission to understand the essence of an ethically coherent society.
The RN-CCM’s lived experience is not extensively researched. Consequently, the role is not well understood by other medical disciplines, human resource departments, other nursing specialties, and newly hired experienced nurses (O’Donnell, 2007; Ramos,
2015). In contrast, recent nursing research identifies risks associated with ethical conflicts for specialty bedside nurses, including nuances of moral distress for those populations 17
(Corley, 2002; Epstein & Delgado, 2010; Hamric, 2012; Pavlish, Brown-Saltzman,
Hersh, Shirk, Rounkle, 2011). Bedside nurses are different from RN-CCMs when addressing conflicts of care (Moffat, 2014). Exploring the phenomena of lived experiences through the perceptions of RN-CCMs is relevant to understanding the causes and outcomes of increasingly complex ethical and practical conflicts for health-care delivery providers today (Zander, 2002 & 2016). This inquiry of RN-CCMs explores the historical influences, meaning-making of the phenomena of conflicts, and implicit personal values in an increasingly complex, prescribed health-care environment.
Significance of this research includes the evolving meaning-making RN-CCMs ascribe to their specific roles in the health care, whether that role is expanding or diminishing.
Research Questions
This research was guided by the following questions:
1. How do certified hospital case managers experience the phenomena of
conflict embedded in their daily professional roles?
2. What influences their decision-making processes other than ethical
codes of conduct?
3. How do certified RN-CCMs’ personal attributes contribute to their
decision-making processes?
4. How do the experiences of decision-making change RN-CCMs’ lives?
These research questions explore the meaning as well as the experiences from which the meanings are garnered from the lived experiences of RN-CCMs in clinical or acute hospital settings. Because these questions address their lived experiences, 18 qualitative methodology—and in particular phenomenology—will be utilized to answer these research questions. At their heart, these questions seek to uncover the lived experiences of RN-CCMs from their own words. Consequently, the qualitative phenomenological study is the best methodological design for this study as it seeks to ascertain the meaning ascribed to the participants’ lived experiences.
Methodology
This project seeks to understand the phenomenology or lived experience of the
RN-CCM participant. Phenomenology is a philosophy “emphasizing the attempt to get to the truth of matters as it manifests itself to consciousness of the experiencer” (Moran,
2000, p. 4). Based on the phenomenology philosophy, the phenomenological research theory supports the selection of a phenomenological methodology to discover and to synthesize the aggregated lived experiences signifying conflict and problem-solving of certified case manager nurses employed in the ecology of an acute hospital setting. The method of interpretive phenomenology described by Van Manen (2016) aims to discover the meaning of personal experience revealed in interviews. The researcher collected trustworthy data using interpretive phenomenological tools of bracketing and condensing, referred to as reduction in the literature. Analysis of transcribed interviews demonstrated prescribed categories describing themes of the human experiences (Saldana, 2013).
Ultimately, this project aims to contribute qualitative research and evolving commentaries on conflict created by ethical and practical dilemmas in health care.
Exploring, describing and understanding the hospital case manager’s lived experiences of medical ethical challenges may inform and contribute to organizational 19 retention strategies, bring attention to the impact on staff by frequent changes in administrative work flows, inspire mentoring to mitigate ethical challenges, and instigate self-care interventions. Adverse outcomes of not investigating this phenomenon include staffing instability; care planning rework; over- or underutilization of hospital resources, resulting in lowered hospital reimbursement; unfavorable patient satisfaction scores; and redundant or unsafe gaps in patient services. Health-care system integrity falters whenever practical and moral dilemmas emerge and professional colleagues perceive the
RN-CCM to be incompetent or patients and families perceive a lack of empathy from the
RN-CCM.
Limitations
Case manager roles exist in many settings and can include social workers, physical therapists, and other areas of professional expertise. This research focuses only on hospital inpatient and hospital network nurse case managers (or a title such as care- coordinator or navigator, representing the case management scope of practice) who hold a certification in case management (CCM). Nurses who have pursued CCM certification were recruited through professional organizations or informal referrals. No specific levels of educational background, prior work experience, geography, or other attributes were limitations.
The limitations of researcher subjectivity based on significant work history in this field location were addressed through epoché, intentionality, bracketing, and a conscious heuristic approach that is an exercise in thinking (Saldana, p. 40), not creating assumptions of meaning. Interpreting meaning of offered experiences requires a 20 researcher’s epoché and reductionism, which have been described as “the power of discovery [that] lies in understanding the world as correlates of consciousness” (Harvey,
1989, p. 94). Also, the data gleaned from these conscious experiences are acknowledged as a learning process for the researcher who applies the mentoring roles from other experienced researchers and resources.
Qualitative interviewing requires a significant investment of time to conduct, interpret, and report the implications of findings. This research format also is reflective.
Observations were not requested in the field due to HIPPA regulations and ethical concerns about confidentiality within hospital environments.
Delimitations
Research delimitations include selection of participants. Discovering ubiquitous themes reflecting conflicts and problem-solving is likely with six to eight hospital or hospital network-based participants. Certified case managers with at least two years of experience in case management were notified of the research before a formal invitation was extended to those interested. Certification in Case Management (CCM) is granted by a comprehensive exam administered by two credentialing institutions: The Commission for Case Management and the American Case Management Association. Anyone actively employed as a case manager for at least two years in any setting is eligible for the exam.
Academic degree, clinical specialty, and gender were not criteria for selection of potential interviewees. 21
Research Ethics
Creswell (2013) explains that the qualitative researcher is obligated explain, without deception, the purpose and nature of the study. An IRB proposal was approved for this research project, including opportunity for participants to read a lay summary before the interview and prepared transcriptions after the interview. The researcher was given permission to contact participants if further information were needed in the signed consent.
Data—including interview recordings, transcriptions, field notes, and other identifiable items—were secured in password restricted electronic files. Any hard-copy notes were held in a locked container at the researcher’s home. Because the research interview could discuss sensitive narratives, confidentiality and anonymity were ensured through the use of pseudonyms for persons and places. Creswell (2015) also cautions against the researcher disclosing personal information because it threatens bracketing and also “reduces information shared by the participant” (p. 175).
Definitions
Accountable Care Organization (ACO). ACOs consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth. This definition emphasizes that these cost and quality improvements must achieve overall, per capita improvements in quality and cost, and that
ACOs should have at least limited accountability for achieving these improvements while caring for a defined population of patients” (McCellan, McKethan, A.N., Lewis, J.L.,
Roski, J., & Fisher, E.S., 2010. p.982). 22
Acute care. Acute care is a level of health care in which a patient is treated for a brief but severe episode of illness, for conditions that are the result of disease or trauma, and during recovery from surgery. Acute care is generally provided in a hospital by a variety of clinical personnel using technical equipment, pharmaceuticals, and medical supplies. (Connecticut Department of Public Health, 2001).
Acute-care hospital. An acute-care hospital is a short-term hospital that has facilities, medical staff and all necessary personnel to provide diagnosis, care, and treatment of a wide range of acute conditions, including injuries (Connecticut Department of Public Health, 2001).
Advocate. A person who assists, defends or pleads for another (CCMC, 2015).
An advocate argues for, defends, maintains, supports, and promotes the interests of another (Merriam-Webster, 2012, p. 19). “Case management professionals often function as advocates, spending a large percentage of their day promoting the identified needs for clients at the service-delivery, benefits administration, and policy-making levels”
(Treiger & Fink, 2016, p. 165).
Case manager. “A professional who collaborates among interdisciplinary practices according to the Code of Professional Conduct” (CCMC, 2015, p. 2). “The case management process is carried out within the ethical and legal realm of a case manager’s scope of practice, using critical thinking and evidence-based knowledge. The overarching themes in the case management process include the tasks described below: Client identification and selection, assessment of a problem/opportunity identification, develop 23 a plan, implement and coordinate, evaluate and terminate care at closure of the episode of care” (CMSA, 2010).
Conflict phenomena for RN-CCM. “An awareness by employees involved in the conflict that discrepancies or incompatibilities, wishes or desires exist among them”
(Jehn & Chatman, 2000, p. 56).
Conflict of interest. “A real or seeming incompatibility between one’s private interests and one’s fiduciary duties” (Powell & Tehan, 2008, p. 573). In particular, third party payers and institutional providers increasingly impose constraints on medical decisions about diagnostic and therapeutic procedures, and many physicians rely on other funding sources for additional income” (Beauchamp & Childress, 2001, p. 317).
Contractualism. The study of agreements to perform work (Merriam-Webster
Collegiate Dictionary 11th ed., 2012, p. 271).
Deontology. The theory or study or of moral obligation (Merriam Webster
Collegiate Dictionary11th ed., 2012, p. 334).
Emotional intelligence. The human ability to monitor one’s own and others’ feelings, to discriminate among these feelings, and to use this information to guide one’s thinking and action (Salovey & Mayer, 1990, p. 185-211).
Ethic. A set of moral principles, a theory or system of moral values, a consciousness of moral importance. Suggests the involvement of more difficult or subtle questions of rightness, fairness or equity (Merriam Webster 11th ed., 2012, p. 429, 807). 24
Interqual. Evidence-based clinical content provide appropriateness of care [and] decision support covering medical and behavioral health across all levels of care as well as care planning and complex care management. (McKesson, retrieved June 18, 2017).
Moral. Conforming to established sanctions codes or accepted notions of right and wrong. Perceptual or psychological rather than tangible (Merriam Webster 11th ed.,
2012, p. 807).
Pay for performance. A contract reimbursement strategy to pay providers based on quality measures rather than fee for service.
Virtue. Conformity to a standard of right, a commendable quality or trait implies moral excellence in character (Merriam Webster 11th ed., 2012, p. 1397).
Summary
As health care has evolved, so have conflicts among different health care groups.
Problem-solving among these groups increasingly requires discernment of different groups’ various definitions of moral actions. Effective problem-solving and collaboration require clinical expertise and matured personal attributes capable of accurately assessing and compassionately communicating options. The RN-CCM historically has been employed to assess, identify requisite needs, and advocate; yet the lived experiences of this pivotal role are not well understood. To make the situation more complex, health care priorities constantly change, resulting in new challenges and protocols. Limitations and delimitations establish a scope for this qualitative phenomenological project. This research is an inquiry to provide meaningful insights for future research and interventions. 25
A brief outline of the remaining content follows. Chapter Two expands a description of literature on bioethics principles, personal attributes useful in conflict management, and the historical context of the case manager role. Empathy and emotional intelligence are discussed in detail because they are considered attributes contributing to successful interventions. Chapter Three defines phenomenological theory and methodology applicable for achieving the purpose of this study. Research questions were answered based on volunteered responses describing daily working environment, tasks relationship, case examples, and effective self-care interventions on and off duty. Chapter
Four contains working biographies in interview data including demographics, work life descriptions offered by each of the eight participants, and a historical perspective of the role at the time their jobs were created. Chapter Five discusses emergent findings and additional theoretical framework. Chapter Six offers implications and recommendations for future study. Overall, the mission of this research is to inform without judgment and benefit those who suffer unavoidable conflicts. Contributing insight on causes and conditions will impact future lived experiences.
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Chapter Two: Literature Review
The literature review for this inquiry is divided into three sections focusing on human attributes, interaction processes, and the historical context of case management in health care. The first section presents six concepts germane to identifying case managers’ personal attributes. The second section presents dynamics in which attributes and other influences interconnect. The process of problem solving requires using attributes and understanding implications for conflict of contributing external facts. The third section offers a historical context of the advocate and collaborator role evolution within health- care systems. Presenting established theories and context in which these themes play out in everyday interactions on these themes prepares the reader for Chapter Four and Five.
The next paragraph clarifies the relationship of these three sections in more detail.
The first section establishes widely accepted literature on biomedical ethical foundations at play in health-care industry conflicts and dilemmas. Literature defining health-care ethics, two constructs of empathy, and manifestations of emotional intelligence have been identified because they offer illuminating insights significant in human experiences when conflicts manifest in health care. The second section concerns dynamics of problem-solving, ethical conflicts, and moral distress reported by nurses (not specifically RN-CCM). The discussion of ethical conflicts and moral distress in nursing research begins with Jameton (1984) and commentaries continue to evolve. Included in this section is a proposed framework of problem-solving processes described by Edge &
Groves (1999). These human experiences and qualities are identified within the RN-
CCMs’ reflections of lived experiences as both an employee and patient advocate. 27
Critical thinking and evidence-based practice (EBP) are essential in clinical professional decision making, and in-patient advocacy within an increasingly prescribed and protocol- driven managed health-care system. The third section offers context: Case managers in the mid-1800s were fieldworkers hired by moral action-oriented institutions or individuals who identified the social value of helping industrial revolution factory workers. Health care in general and this scope of practice in particular have experienced change due to confounding regulatory and standardizing reimbursement regulations. For example, resource allocation decisions depend on ethical principles and virtues of the dominant culture in combination with cost factors. This is an example of how the historical evolution of health care has a role in case managers’ lived experiences.
Offering context for the attributes and interactions outlined here enhances insights into various participants’ lived experiences as RN-CCMs. This paper summarizes the historical changes leading to the 1990s as a distinctive growth phase for health care industry funding structures. A new role, called the case manager, became essential to assume complex collaborative responsibilities among various vested groups and hierarchies including hospital, insurance, clinicians, and patient-family. Hospitals started hiring or promoting bedside nurses deemed ethically mature and clinically knowledgeable. Over time more changes in the industry have occurred; this is reflected in the participants’ experiences. Those who were hired at a later period were unaware of the change of decreasing creative care planning and increasing scrutiny of benefit allocation.
Also, this increased scrutiny created a need for outpatient surveillance to meet protocol metrics. In early 1990s a certification process established metrics to identify advanced 28 and well-honed skills. Each participant came into the advocacy role during different stages of case management coalescing into an advanced practice role of expertise and scope of interventions.
The literature offers commentaries supporting possible content for individualized interventions specific to mitigating individuals’ perceptions of unsatisfactory conflict resolutions. Constant, occasional, seemingly insignificant or job-altering experiences contribute to conflict in a role as advocate and mediator.
Ethics, Codes of Conduct, Empathy, and Emotional Intelligence
Understanding conflicts in the health-care context is best established in literature defining ethical themes embedded in professional codes of conduct, empathy, and emotional intelligence. “Ethics is a generic term for various ways of understanding and examining a moral life.... Morality refers to norms about right and wrong human conduct” (Beauchamp & Childress, 2001, p. 6). Edge and Groves (1999) define ethics as
“crucial reflections about morality and rational analysis of it; a generic term for the study of how we make judgments regarding right and wrong (p. 298)”. A newer category, health care ethics, addresses ethical issues and problems emerging in the context of delivering care to actual patients and is therefore supported by codes of conduct. Codes of ethical conduct are derived from “the universal principles to bring about the goals of the profession” (p. 51). Empathy for purposes of this project is “feeling another’s pain; perceiving accurately another person’s feelings and the meaning of these feelings”
(Bullmer, 1975, p. vi). Emotional intelligence is social: Taking intentional steps to recognize, understand, and manage one’s thoughts, feelings, and reactions in situations so 29 an insightful response and communication can result (Goleman, 1995). Each of these concepts is discussed in this section.
Ethics. Universal principles or morality and ethical standards are adopted by subcultures and social groups. These groups define moral conduct based on abstract concepts of jurisprudence and fairness. Social ethical codes of conduct are further refined and adapted according to a specific social group’s culture and purpose. Interpretations of ethical codes establish criteria of right and wrong depending on the bias of the group
(Slote, 2007, p. 11; Teich, 1992, p. 99). Eight universal “codes of ethics” were first identified in 1847 by the AMA (Beauchomp & Childress, 2013, p.13). These remain relevant in bioethics and morals today and are listed in Table 2.1.
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Table 2.1.
Relationship of Moral Principles, Rules, and Action to Corresponding Virtues
Principles Corresponding Virtues
Morals Respect for autonomy Respectfulness Non-maleficence Non-maleficence Beneficence Benevolence Justice Justice or fairness Rules Veracity Truthfulness Confidentiality Confidentiality Privacy Respect for privacy Fidelity Faithfulness Ideals of Exceptional Exceptional forgiveness Action forgiveness Exceptional Exceptional generosity generosity Exceptional kindness Exceptional kindness Note. From Principles of Biomedical Ethics, 7th ed. by T.L. Beauchamp, J.F. Childress,
2013, p. 381. Copyright 2013 by Oxford University Press. Adapted by permission.
These categories are the basis for codes of professional conduct by which RN-
CCMs advocate for patients in their professional interactions. Further description of these established terms and relationships follow. Figure 2.1 illustrates in general terms the ethical dynamics informing ethical dilemmas experienced by case managers. This figure is revisited in chapter five. 31
Figure 2.1. Relationship of society’s moral virtues and values informing ethics in RN-
CCM Codes of Conduct. Ethical dilemmas of case managers are created from interactions informed by social ethics, health care ethics, and personal attributes.
The social principles establishing moral actions also inform biomedical, health care, and personal values relevant to the case manager. Dilemmas for the case manager emerge when moral actions are not congruent with those of other groups within the health care system and possibly within larger society. Coperu (2008) reinforces the idea that the epistemology of ethics is derived from social values and contributes to distinguishing reasoning from argumentation. Basically, a studied process of sorting out knowledge from an opinion [author’s italics]. Coperu believed deonatology (duty) of ethics [is] an 32
“antidote to positivistic bureaucratic-like behaviors and…contributes to the renovation of professional practices” (pp. 304-308).
In addition to general social norms, professional health-care morality is defined based on specialized training and a commitment to provide important services to clients or customers (Beauchamp & Childress, 2013, p.7). In biomedical ethics, principles and virtues defining the character of health-care professionals are compassion, discernment, trustworthiness, integrity, and consciousness (Beauchamp & Childress, 2013, p. 33). The axiological foundations of what is considered a moral act depend on how the group defines and social members assimilate normative values contributing to ethical acts of moral living. Health-care professionals’ conduct is mandated to include these principles, virtues, and types of moral actions (Beauchamp & Childress, 2013; Edge & Groves,
1999; Lo, 2000; Slote, 2007).
Principles are analytical frameworks, rules are more specific, and virtues are morally and socially valued character traits (Beauchamp & Childress, 2001, pp 12-27).
Health-care professionals measure moral action by four virtues labeled autonomy, non- maleficence, justice, and beneficence. These principles and virtues determine how moral actions are judged by society’s norms. This judgment contains “right and obligatory
(truth telling), wrong and prohibited (murder), optional and morally neutral (neither wrong nor obligatory), or, finally, optional but meritorious and praiseworthy”
(Beauchamp & Childress, 2001, p. 40). Figures 2.2 through 2.5 illustrate the content of
Table 2.1, presenting the four essential biomedical ethical principles and corresponding 33 virtues and actions established by Beauchamp and Childress (2013, p. 381) informing codes of conduct for case managers.
Moral Virtue: Respectfulness
Rule of Virtue Rule of MORAL Respectfulness: Autonomy: PRINCIPLE: Truthfulness Veracity Automony
Ideal Action: Forgiveness
Figure 2.2. Autonomy principle of the virtue of respectfulness informs actions of forgiveness. These principles and virtues are supported by truthfulness and veracity.
Adapted from Principles of Biomedical Ethics, 7th ed. by T.L. Beauchamp, J.F. Childress,
2013, p. 381. Copyright 2013 by Oxford University Press. Adapted by permission. 34
Moral Virtue: Non-Maleficence
Rule of Non- Rule of Virtue: MORAL PRINCIPLE: Maleficence: Non-Maeficence Non-maleficence Confidentiality Confidentiality
Ideal Action: Generosity
Figure 2.3. Non-maleficence principle of the virtue of doing no harm informs actions of generosity. These principles and virtues are supported by rules of confidentiality.
Adapted from Principles of Biomedical Ethics, 7th ed. by T.L. Beauchamp, J.F. Childress,
2013, p. 381. Copyright 2013 by Oxford University Press. Adapted by permission.
35
Moral Virtue: Justice or Fairness
Rule of MORAL Rule of Justice/Fairness: PRINCIPLE: Justice/Fairness: Fidelity Justice Fairness
Ideal Action: Kindness
Figure 2.4 Justice principle of the virtue of justice or fairness informs acts of kindness.
These principles and virtues are supported by social rules of fidelity and fairness. Note:
Adapted from Principles of Biomedical Ethics, 7th ed. by T.L. Beauchamp, J.F. Childress,
2013, p. 381. Copyright 2013 by Oxford University Press. Adapted by permission. 36
Moral Virtue: Benevolence
Rule of Virtue Rule of MORAL Beneficence: Beneficence: PRINCIPLE: Respect for Privacy Beneficence Privacy
Ideal Action: Compassion
Figure 2.5. Beneficence principle is the virtue of benevolence informs acts of compassion. These principles and virtues are supported by rules respecting privacy. Note:
Adapted from Principles of Biomedical Ethics, 7th ed. by T.L. Beauchamp, J.F. Childress,
2013, p. 381. Copyright 2013 by Oxford University Press. Adapted by permission.
Identified virtues also inform codes of conduct (morality based) and are profession specific. Professional codes of conduct are influenced by overarching health care standards of biomedical ethics determined by normative (community authority) morality: fidelity (faithfulness), veracity (truthfulness), discernment (justice/fairness), empathy (forgiveness, generosity, compassion, kindness), and a duty to represent professional advocacy of caring (respectfulness, autonomy, confidentiality). “Five focal virtues [derive moral living as reflected in health care relationships include] compassion, discernment, trustworthiness, integrity, and consciousness” (Beauchamp & Childress, 37
2013, p. 31). In brief, non-normative (universal authority) ethical standards or rules that inform bioethics are based on theories of justice (Edge and Green, 1999, p. 40) and forgiveness (Beauchamp & Childress, p. 39).
The Commission for Case Management Certification bases RN-CCM codes of conduct on these ethical principles identified by ethicists Beauchamp and Childress are autonomy, non-maleficence, beneficence, and justice [associated rule is fidelity] (CCMC,
2015, p. 4). The following paragraphs discuss the impact of codes of conduct when health care groups interact. This establishes one reason why conflicts within health care are complicated.
Codes of conduct. Health care bioethics are based on a “commitment to excellence in clinical practice and to a set of appropriate moral, ethical, and social behaviors” (Edge & Groves, 1999, p. 1) aligning with the previously stated ethical principles and virtues. The rules of professional morality are vague, so that different interpretations of duties emerge related to these rules. Within health care paradigms “the codes of conduct are created to reduce vagueness.... The problems of professional ethics usually arise from conflicts over professional standards or conflicts between professional commitments and commitments of persons outside the profession” (Beauchamp &
Childress 2013, p.7).
In hospitals, professional groups reconcile dilemmas based on divergent priorities and codes of conduct constantly. At least 100 specialist professional roles exist in health care today (Edge & Groves, p. 1). Ethical standards and codes of conduct established by different social groups are driven by different priorities, such as financial investments, 38 medical treatment options, or individual standards of practice. When these groups interact, “conflicts between moral requirements and self-interest sometimes produce a practical dilemma rather that a moral dilemma” (Beauchamp & Childress, 2001, p. 11).
An individual’s moral duty is to abide by morally right codes of practice based on codes of ethical conduct generated by professional institutions and licensing agents.
Personal moral standards are individually internalized interpretations of social ethics developed over time and are influenced by cultural norms, personal background, and life experiences (Beauchamp & Childress, 2001; Edge & Groves, 1999; Lo, 2000). “Morals are concerned with the judgment principles of right and wrong in relation to human actions and character. Moral duty is an act or course of action that is required by one on the basis of moral position” (Edge & Groves, 1999, p. 300), which includes the moral duty of advocacy for health care professions.
Conflicts both small and large are inevitable. On the front end, vested parties experience conflicts and mitigate them issue by issue, each applying what they believe to be moral conduct. Conclusions of what justifies right and wrong choices among different groups can become muddled; the most powerful influence can often seem as the one least advocating for the patient. An individual’s capacity to be compassionate or empathetic can be overwhelmed when vetting best options. The concept of ethics justifies a phenomenological framework for this research. The lived experience is not to be judged but understood from the view of the RN-CCM.
Empathy. In addition to a person’s moral perspectives, empathy contributes to the experience of ethical interpretations of justice and forgiveness (Banja, 2007; 39
Beauchamp & Childress, 2001). “The basic meaning of empathy is derived from
Lipps’[sic] 1987 writings referring to Einfuhlung, ‘Feeling oneself into’ and later translated by Titchner in 1910 as empathy” (Goldstein & Michaels, 1985, p. 5). Kohut
(1981, reprinted 2010) established a context for empathy between humans to include
“thoughts, wishes, feelings, and fantasies…have no existence in physical space, and yet they are real, and we can observe them as they occur in time: Through introspection in ourselves, and through empathy (i.e. vicarious introspection or ‘extrospection’) in others.
The listener cannot see what’s going on inside the other so asks the speaker to report what is going on in the internal life” (Kohut, 1981, p. 125). Empathy, the capacity to see from other’s perspective, is a human trait that develops over time, contributing to advocacy. In 1932 Hoffman identified six stages of empathic development in humans of which the first five are classical conditioning metrics. The sixth stage is a “greater cognitive maturation and depends much more on purposive action” (Goldstein &
Michaels, p.15).
The experience of empathy in adulthood is grounded in social-centric ethical standards and can reflect biased interpretations of ethically valid justice and mercy.
Bennett (2001) defines “empathy as mode of relating in which one person (or animal) comes to know the mental content of another, both affectively and cognitively at a particular moment in time and as a product of the relationship that exists between them”
(p.7). By 1975 the scope of empathy “was no longer viewed as purely perceptual awareness of an individual’s affect or sharing of feeling, but rather an ability to understand a person’s emotional reactions in consort with the context” (Goldstein, 1985, 40 p. 4). In 1984, Hoffman proposed that the same capacity for empathic affect, for putting oneself in another’s place, leads people to follow certain moral principles (in Goleman,
1995, p 105). In contrast, Hooker (2015) examined conceptual confusions defining empathy less in terms of emotional responsiveness and more toward the phenomena of understanding and knowing—not sympathy or similar terms describing self/other relationships (p. 544). Hooker, as well as other authors, refers to empathy having many nuanced definitions (Jamieson, 2014; Slote, 2007). “Inducing empathy is central to both moral education and moral development. Moral claims inducing empathy are central across the entire range of an individual’s political morality” (Slote, p. 4). “Understanding empathy by examining its origins within phenomenological tradition, as a mode of intersubjective understanding, offers a different and profitable approach” (Hooker, p.
541). These contextual frameworks inform the discovery about emerging themes of empathy as a lived experience for RN-CCMs.
Emotional Intelligence and Empathic Maturity. A less established concept on empathy concentrates on adult developmental goals and stages of life. Goleman (1995) focused on internal motivations to attain specific social goals in adulthood in his best- selling book Emotional Intelligence. Goleman described how empathy is embedded in emotional and social intelligence complexes and is essential in social interactions, for better or worse. Empathy is the glue that combines ethics and social contributions.
Goleman is a psychologist and author primarily interested in how individuals learn to self-regulate internal responses to external events and the adult stages of development 41 and requisite responsibilities. Goleman (2007) articulated that empathy comes in three qualities:
1. Cognitive (mental “under-emotional” response based on thought and
culture), applicable to cognitive empathy toward organizational contracts
and capacity to provide services;
2. Emotional (i.e., emotional contagion or overemotional identification),
occurring in varying degrees and most often triggered by identifying
patient expectations and external obstacles or personal resistance
accessing those expectations; and
3. Compassionate (self-regulation and psychological flexibility) toward self
and others through attunement and awareness of internal responses. This
last category is an altruist form of empathy describing “a state of
awareness of the other’s experience using cognitive and affective
reflection and harmonized by the observer based on mindfulness or
psychological flexibility” (Goleman, June 12, 2007). Goleman contends
that lapses among these categories can be remedied with the right effort
(Goleman, 1995, p. 44). Goleman’s categories of empathy present
challenges when applied to complex interactions. However, these
categories inform an understanding of emotional or social intelligence
when examining communication patterns. The retrospective interviews
conducted for this project were reflections of events without the researcher
observing events for affect or content. 42
Olsen’s empathic maturity, which describes engaging empathy with other, presents another framework applicable to reflections about lived experiences. This theory recognizes that empathy matures over time, similar to the phenomena of emotional intelligence. Olsen describes empathic maturity in a continuum of three levels as a
“cognitive theory of moral point of view in clinical relations” (Olsen, p. 44). Olsen includes quality of value and meaning that the patient offers the nurse and defines robust empathic maturity as a schema most inclusive of others, not only of self vs. others (Olsen, p. 36–37). In this structure, moral distress may emerge in less matured empathy for which conflict is perceived as duality and not intersubjective: Dissonance results when the nurse perceives a lack of “mutuality of meaning” (Olsen, p. 40). Olsen suggests empathy is based on a cognitive three-level structural theory (see figure 2.6):
1. Level I describes egocentric perceptions: The patient holds value based on
meeting the needs of the care provider (metrics, quality measures) so
moral distress is less likely because of a lack of attaching importance to
others (Olsen, p. 40).
2. Level II describes the care provider perceives negative behaviors of the
patient, mitigates the patient’s responsibility by use of history which
renders behavior ‘understandable’. In this level sick vs. intentional
behaviors are difficult to reconcile and moral distress can emerge (Olsen,
p. 41).
3. Level III confers humanity of everyone and therefore inter-subjectivity
must be negotiated. The patient is responsible for behavior but that 43
behavior ‘no longer is a valid influence on the personal connection of the
care provider’. The nurses’ positive regard is not impacted by patient’s
behavior, emoting concerns or silent attunement (paraphrased from Olsen,
2001, pp 36-46).
Olsen’s description of empathic maturity and task-relations offers a scaffolding to define the dynamics of RN-CCM advocacy in conflicts of caring described in chapter 5.
Olsen reconfigures Goleman’s cognitive and compassionate categories of empathy by articulating possible meaning-making of the nurse as self-professed advocate in a caretaking role. Table 2.2 offers a visual comparison of Goleman’s and Olsen’s empathy categories. A caveat that may contribute to risks associated with moral distress: Any caregiver may be restricted by organizational or task boundaries to function at Level III compassion due to expectations. Conflict of caring may present risks of moral distress because of external restrictions or empathy lacking attributes associated with Olsen’s
Level III category of empathic maturity.
For Olsen, empathy manifests in three approaches when considering or interconnecting with others. Olsen’s theme of empathic maturity illustrated in figure 2.6 is compared to Goleman’s theme containing three separate forms of empathic themes shown in Table 2.2. Figure 2.6 Olsen’s Empathic Maturity 44
Level I: Level II: Level III Self vs Other Self = other if valuable to self Self SAME as other
Example: Example: Example: Drug addicts are self destructive Meeting metrics of 95% Compassion without compliance judgment
Figure 2.6. The levels of empathic maturity.
Table 2.2
Empathy Categories Compared Between Goleman and Olsen
Goleman Olsen
Themes of Themes of Qualities of Theme Qualities of Theme Empathy Empathy
Cognitive Self-regulation and Empathic Self not Other; psychological Maturity I minimal or no flexibility identification with Other Emotional Emotional contagion Empathic Self accepts Other or over emotional Maturity II conditionally identification
Compassion Response based on Empathic Self accepts Other thought and culture Maturity III Unconditionally and without judgment
45
Compared to Goleman, Olsen provides more nuanced transitions of empathic capacity: Maturing empathic skills are less judgmental. Empathic maturity and EI are required by case managers embroiled in daily conflicts. “Demonstrative emotional outcry for justice or combative bullying behaviors were absent and not implicated as effective techniques identified in conflict management research” (Lindy & Schaefer, 2014; Wright,
Mohr, & Sinclair, 2014). The RN-CCM code of conduct and empathy contribute to effective collaboration.
Ultimately, ethics, empathy, and emotional intelligence represent curious intangible concepts explored through phenomenological research. Each concept refers to human experiences in relationships and actions between self and others. Also, each describes internal experiences influenced and sustained by implicit social bias and cultural moral standards. The RN-CCM volunteered reflections are informed by ethical codes of conduct, lived experiences of moral or practical dilemmas and conflicts, and the application of empathic knowing and critical thinking skills. A standard problem-solving process taught to nurses, collaboration, and mediation responsibilities of daily responsibilities are defined in the next section.
Problem-Solving Process, Ethical vs. Practical Conflicts, and Moral Distress
Problem solving. Groups with vested interests (organizational, clinical, and self) frequently commingle in patient care and the result is intersecting ethical codes of conduct due to numerous priorities. As stated, these codes represent values of a moral life as defined by social norms. 46
Value theorists Kohlberg, Piaget, and Gilligan have…provided models that show
maturation and acquisition of value orientation throughout our childhood. The
highest level of maturation described by Kohlberg and Piaget seems to be an
autonomous decision-making system based upon legalistic equality (Edge &
Groves, 1999, p. 16).
The commingling of professional ethics and virtue values in the health-care system is unavoidable in decision-making. Therefore, effective problem-solving processes are required in health care interactions. Effective problem-solving requires critical thinking skills (accurate prioritizing and assessments in medical care planning) and evidence-based practice (opinion versus knowledge) reflected in Edge and Groves’
(1999) theory of the problem-solving process in 6 stages summarized below:
1. Identify and describe the characteristics of the problem, including
concerned parties, and who is charged with making the decision.
2. Gather facts and articulate fact from opinion. Collect necessary
documentation and anticipate what facts may change.
3. Examine the options: The more options, the more likely a solution will be
found.
4. Consider outcomes for potential options: For individual, for equality.
Refer to principles (ethics) options support or sacrifice: Virtue,
utilitarianism, duty-oriented?
5. Act on decision.
6. Assess and evaluate results (Edge and Groves, p. 36). 47
When conflicts emerge between competing interests and values, then competent problem-solving benefits from a collaborative critical thinking problem-solver contributing evidence-based practices. This role requires adult competency to a) empathize with the motivations of competing ethical practices, b) collaborate toward viable clinically safe solutions, and c) practice what is perceived to be ethically sound advocacy preserving a patient’s right of autonomy based on restricted resource allocation.
Ethical vs. practical conflicts. Conflicts have different qualities. Ethical conflicts lead to dilemmas when priorities of powerful financial incentives, clinical protocols, and advocacy collide. Colliding ethical priorities and the practical aspects of doing business such as communication patterns and burdensome administrative requirements create challenges in decision-making. These events are conflicts when doing business means commingling discordant ethics or practice. Ethical conflicts can “create dilemmas, violate a moral obligation…and leave a trace of moral violation” (Beauchamp and Childress,
2001, p. 12). In contrast, practical dilemmas are “self-interest” (Beauchamp & Childress,
2001, p. 11) or “external constraints (e.g., inadequate administrative support, incompetent caregivers, system factors)” (Hamric, 2012, p. 41), while a bureaucratic dual system of authority creating hierarchies (Jameton, 1984, p. 41) can create practical conflicts.
However, these “practical dilemmas are not necessarily competing ethical priorities”
(Beauchamp and Childress, 2001, p. 11).
Moral distress. A risk of dissonant ethical problem-solving resulting in moral distress is ubiquitous in health care decision-making. Moral distress risks for bedside nurses and other health-care professionals has received significant attention, beginning 48 with Jameton (1984) and further developed by Corley (2002); Hamric, Borchers, and
Epstein (2012); Varcoe, Pauly, Storch, Newton, and Makaroff (2012); and several others.
Considerable effort has been made to create theories about the concept of moral distress
(Barlem & Ramos, 2015; Fourie, 2013; Lawrence, 2011) for bedside nurses. Research suggests that bedside nurses perceive unethical treatment as unresolved, unethical, or dissonant and as bioethically and morally conflicting actions or problem-solving predicaments. For the nurse, this perception creates risks of moral distress or moral vulnerability and impacts perceptions of effectiveness in patient advocacy (Browning,
2013; McCarthy & Gastmans, 2015; Pavlish, Brown-Saltzman, Jakel, & Fine, 2014).
Ultimately, moral distress or dissonance identified in bedside nurses has been associated with outcomes of adverse coping behaviors, job dissatisfaction, and expensive resignations that are estimated to affect 15% of the nursing workforce (Pendry, 2001, p.
217). Validated tools created to detect internalized moral values or empathic qualities using hypothetical scenarios or thermometer prototypes are not applicable to the RN-
CCM scope of practice.
Understanding the evolution in research and professional commentaries is beneficial in comprehending current views on ethical dilemmas, conflicts, and moral distress (Burston & Tuckett, 2012; Hamric, 2012). Not all health-care conflicts and dilemmas are ethical; outcomes of moral distress continue to be refined. For example,
70% of selected articles in a 2013 issue of The Journal of Bioethical Inquiry focused on the depth and breadth of moral distress concepts, causes, and implications and future inquiry. Numerous nursing theories proposed to describe moral distress have disparate 49 methodology and theories (Johnstone & Hutchinson, 2015, p. 5). Academics agree the defining the causes and conditions of ethical stress for bedside nurses has been inconsistent (DeKeyser, Ganz, & Berkowitz, 2011; De Villers & DeVon, 2012).
Recently, authors have begun to challenge the reality of moral distress as phenomena a priori. “Moral distress is emerging as a promising vehicle from which to evaluate the experiences of nurses and other health-care providers as they seek to enact the ethical foundations of their practice” (Peter & Liaschenko, JBI, 2013, p. 314).
The only published research devoted to the hospital case manager’s experience of ethical dilemmas explores the perceptions during the transitional process when RN-
CCMs enter the profession from other bedside positions (O’Donnell, 2003). The impact on organizational ethics was a focus. In this phenomenological interpretivist research design, O’Donnell (2007) identified the following four recurring themes among the 15 interviewed RN-CCMs who had been employed for three years (2) or less (13): “Case management as a balancing act, framing contentious options, speaking for vulnerable individuals, and responsibility without power” (p.220). O’Donnell’s 2007 article summarizes dilemmas in problem-solving:
[D]irecting patient care services [occurred] though co-ordination, advocacy, and
referral.…The Code of Ethics assign the Case Manager to provide services for
inherent human dignity…. However, managed care has imposed constraints and
limitations on nurse case managers as they are mandated to adhere to utilization
practice guidelines that hamper their ability to be autonomous advocates of
patients’ best interest.... [RN-CCM] is tasked with delivering the results of 50
[organizational priorities] to the patient and their family [and] may experience
conflict in their efforts to work within the organizational rules (p. 161).
Implications of these relentless interactions in care planning may also lead RN-
CCMs to offer responses that suggest risks of moral distress, compassion fatigue, and possible transfer out of a job that contains contentious expectations incongruent with one’s own values. O’Donnell identified mitigation strategies within the organization as supportive managers, transparency about cost and quality decisions, organizational training, recognition of interdependence among other health care disciplines, proactive identification, and measuring and reporting “outcomes with accountability” (p. 231).
Complex relationships described in this chapter emerge among the values of ethics in health care, competing interests, everyday actions, and the risk of moral distress as a part of the daily RN-CCM’s experiences of conflict.
Understanding the dynamics influencing the lived experiences of RN-CCMs will result in more effective interventions. This understanding will also inform those who are curious about employment as or certification in case management. Unlike most research on this topic which offers little remediation under control of the RN-CCM, this project’s long-term goal is to identify emerging themes susceptible to meaningful strategies of personal reflection about perceptions and responses to conflicts and subsequently enhance the skill and capacity of RN-CCMs to reframe and mitigate destabilizing and unrealistic internal meaning-making to promote sustained problem-solving resilience and effectiveness. 51
Historical Health Care Context and Case Management Duty
This section is divided into three topics: Chronological events in health care influencing case management, professional codes of conduct including certification development, and a current range of RN-CCM responsibilities in daily operations. The historical synopsis establishes how the collaborative caregiving role of RN-CCM evolved. The role emerged in the late 1800s due to a lack of oversight in non-acute settings and has become essential due to pervasive regulatory demands on health-care providers while increasingly restrictive clinical resource utilization has influenced ethics pertaining to distributive justice. The second section examines the relationship between historical changes in health care and codes of conduct guiding case management activities. This sets the context for the evolution of certification establishing a unique need and clinical expertise in conflict management when various priorities collide within and among health care providers, and often affect patient care choices. The third section offers an overview of current RN-CCM responsibilities in daily operations. These topics add depth to the context in which a case manager’s role is defined. Participants’ reflections of their experiences reveals their personal attributes and changes over time. In this study, participants’ various and shifting scopes of practice reflect industry changes over time and are found in Chapter Four.
How social governance begat professional case management advocacy. The health-care advocate role in America first began in the late 1800s (Treiger & Funk,
2015). At that time, charity organizations funded limited services in the community inspired by perceptions that the value of caring for the sick and poor was virtuous and 52 ethically mandated. An oversight community service coordinator role was created to ensure “accountability, service quality, and consumer protection.” (Treiger & Funk, p. 7).
In the 20th century, the case manager’s role evolved significantly from nonacute oversight assessment.
An RN-CCM understands the variety of intricacies of reimbursement affecting where, when, and how patients receive care. The Social Security Act (SSA) signed in
1935 by Franklin Roosevelt established a social insurance benefit for the elderly as part of the New Deal. In 1965 Congress amended that act to establish Medicare, thus beginning a significant role in health-care accountability and resource utilization that continues today. Medicare became the standard criteria for reimbursement of services for health care providers and, eventually, health-care systems.
If Medicare covered a service, then private insurers followed the lead. Private insurance companies also created policies to supplement Medicare benefits (Medigap), adding more complexity to interpret how covered benefits are reimbursed. Hospitals serving Medicare and Medicaid patients, including those on disability, benefited by having a knowledgeable professional to supervise services (Treiger & Fink-Samnick,
2016). When Congress amended the SSA, the case manager’s scope of accountability in decision-making increased. The focus was on “access and entitlements to quality” (Cesta
& Tahan, 2003, p. 15). Medicare responded to infringement of patient rights by creating compliance regulations and requirements for all providers (Powell & Tahan, 2008;
Treiger & Funk, 2016). Case managers have proliferated under this evolving political and financial complexity. Social workers, physical therapists, nurses, and others are now 53 hired and called case managers by almost every group seeking reimbursement for health care services from government and private insurance.
The federal government reimburses health care providers for Medicare and
Medicaid services on a fee-for-service basis. Before 1973, providers billed without much oversight or prior approval as long as the service was medically necessary. Unscrupulous providers billed for unnecessary or duplicated services; little oversight was available.
Two significant laws catalyzed a need for competent collaborators in the field.
The Health Maintenance Organization (HMO) Act of 1973 approved managed health-care policies for private insurance companies. The legislation was intended to address the need for safe and effective cost containment as prices for provider services increased due, in part, to technological advances in treating certain conditions, such as kidney failure or cardiology. To contain increasing costs in fee-for-service insurance plans, health-care companies created managed care plans. Because these plans provided cost-effective employer-sponsored insurance packages and introduced policies intended to conserve resources. Managed care quickly dominated employee group insurance benefit plans because employee premiums were lower than those for fee-for-service plans. Managed care plans managed access to high-cost services by restricting benefits using pre-approved referrals and by restricting options to network providers who would accept lower reimbursement, particularly for high-cost services. Insurance companies also initiated managed Medicare plans that appealed to fixed-income retirees. These immense changes created significant pressure on hospitals to contain costs. The result of these reimbursement changes was declining flexibility and increasing complexity for 54 providers to create individualized cost-effective care plans. Populations with limited decision-making capacity or understanding of their condition required advocacy.
Second, the Prospective Payment System (PPS) system used to reimburse for
Medicaid and Medicare services led to the creation of Diagnostic Related Groups (DRG) in the 1980s to provide a framework of uniform reimbursement based on medically necessary services. The provider became responsible for maintaining established guidelines for quality of care and simultaneously containing health-care utilization. The provider made a profit if the patient was treated and discharged before allotted DRG funding (based on days of stay) was used up. Under this model, patients were discharged from hospitals earlier and insurance rarely approved continued days of stay beyond the
DRG because additional days meant an increase in the cost of care.
Health-care costs were rising and reimbursement was becoming harder to secure.
Hospitals absorbed costs for mandated services that government funded programs, such as Medicaid, did not adequately cover. Inconsistent insurance policies and coverage changes led to the need for more oversight. Clinically competent, system-savvy collaborators helped save money. In 1986, the Center for Case Management was initially founded as a consultation service to educate health-care organizations that were beginning to identify the value of case management as a nonbillable resource to contain costs by adhering to compliance regulations, engaging in protracted approval processes, and avoiding or appealing denials for payment when possible. The RN-CCM collaborates across disciplines and problem-solves ways to maximize time-consuming requirements necessary to access patient benefits. 55
In 1990 two important events affected case managers. First, “[t]he Patient Self-
Determination Act (PSDA) provided a way for Medicare and Medicaid patients to express treatment care preference at the end of life” (Hunsaker & Mann, 2013, p. 841).
“PSDA is evidence that healthcare regulations were now perceived as ineffective in providing patients with information about their rights in self-determination” (p. 843). The
PSDA legal directives were established to include the patient in health-care decisions focused on End of Life (EOL), the ethics of caring, virtue values, and knowledge of outcomes. Second, the Utilization Review Accreditation Commission (URAC) was established to “provide review and accreditation for utilization review services/programs provided by freestanding agencies [hospitals]: URAC Case Management Accreditation
Standards set standards for case managers” (Powell & Tahan, 2008, p. 243). These two events encouraged greater use of case manager services to reduce to risk of redundant, inappropriate, or deficient services for the patient.
Two participants in this study (BH and CM) began their case management work about this time and were among the first to take the certification exam in 1993. My own role in case management began in 1995 when I was an insurance company pediatric catastrophic case coordinator, twenty years after nursing school graduation. This beginning of professional recognition for case managers’ value in oversight and negotiating services included cost savings by approving covered services to avoid exacerbation of and hospitalization for chronic illness. The cost-benefit ratio approach was creative and empowered advocacy for providing health care services. The 56 experiences of participants who were case managers in the 1990s informs perceptions about the current, more prescribed role for case managers as described in chapter five.
In 1992, a national forum, the National Case Management Task Force, convened
“because of the growing concern that there were no standards or qualifications of people calling themselves case managers” (p. 256). One outcome of this task force was to create the Commission for Case Management that was responsible for setting standards of practice. They created the certification exam beginning in 1993 requiring prequalification of at least the equivalent of 2 years of full-time work experience in addition to a professional health-care license in nursing, social work, or rehabilitation therapies. The
Case Management Society of America (CMSA) was the first professional organization to which any case manager could belong. In 1999, another professional case management organization established certification by examination: The American Case Management
Association (ACMA). Both professional organizations remain active, each with thousands of members. Without intention, all research participants were certified by
CSMA; only BH holds an additional certification with ACMA. The range of certification longevity ranged from BH and CM, who took the first certification exam in 1993, to MC who has been certified five years. The possible impact on this and other historical details are discussed in chapter five.
In the context of growing oversight and benefit scrutiny, the cost of providing health care ballooned regardless of increased bureaucracy. In response, insurance companies and government next attempted to contained costs by creating a capitated payment system in 1997 based on basic service protocols (ambulance rides, home care 57 services, infusion therapies) for high-risk populations (e.g., those with diabetes, asthma, back pain). “Only recently have ethicists realized that modern ethical issues overlap with economic ones” (La Puma, 1996, p. 160). Lo (2000) identifies major themes today that include conflict of interest, patients’ decision-making ability, and unwise decisions by patients (p. 13). This was the time period when I left my insurance case-management position and was hired by a large hospital to facilitate the cumbersome and fluctuating regulations imposed by managed-care contracts.
From the beginning Case Managers have been increasingly embedded in the transitions in health management and implicit conflicts, while also expected to assess and identify high-risk patients, be experts in accessing benefits for patients, and to oversee compliance with health-care regulations. As health care becomes more complex the system of insurance and government programs continues to regulate and restrict reimbursement for normal recovery, including penalties in the form of reduced provider payments for those patients with chronic conditions who do not meet prescribed stability markers based on laboratory values, overutilization of emergency services, or readmissions within a set window regardless of the reasons for these needs.
Increasingly, financial risk from reimbursement shortfalls, rising operating expenses, and budgeted profit margins can destabilize organizations. Beginning the mid
1990s hospital administrators increasingly appreciated the value-added necessity of the professional oversight of care planning and collaboration provided by case managers who would communicate directly with insurance companies. Experienced nurses, often from specialty bedside positions, were hired as all-in-one discharge planners, utilization 58 experts, and compliance monitors in order to maximize reimbursement for inpatient services, efficient care planning, and advocacy during transitions of care. These employees, often low-cost social workers or high-cost nurses, were titled as case managers or care coordinators. The nurses possessed considerable clinical knowledge and bedside experience. The social workers assumed the nonclinical and often psychosocial aspects of patient needs that affected treatment planning. Working nurses learned new skills to apply clinical expertise, including how to negotiate with providers and insurance companies to navigate time=consuming detailed protocols. These communications were mandated for pre-approval and access to high-cost benefits. The case manager communicates frequently; submits repetitive or technically detailed documentation; collaborates with physicians, insurance, and families to access benefits; and initiates appeal protocols with payers when hospitals or physicians are denied pre-approval for benefits which they feel would benefit the patient.
Standards of practice and codes of conduct. Anyone can be a case manager in title. Only licensed professionals with a commensurate job description and sufficient longevity in a case management position can qualify to sit for certification. Ethical principles and mature critical thinking skills are the basis of certification by peer organizations. Standards of practice set up “acceptable levels of performance or expectation for professional intervention or behavior associated with one’s professional practice” (Powell & Tahan, p. 243). The Commission for Case Management Certification
(CCMC) is the organization preparing the examination for CCM (certified case manager).
The intent of CCMC is “to protect the public interest” (CCMC, 2015, p. 2). The National 59
Board of Case Managers and its professional organization ACMA (American Case
Managers Association) offers a hospital and health care network case management certification, the ACM credential (Accredited Case Manager). CCM was established before ACMA. CCMC has a professional code of practice. ACMA has guidelines called
Scope of Service, which outline professional expertise or liability of specific duties when applying ethical standards and advocacy. For example, ACMA guidelines designate oversight and delegation of bedside assessment duties to nonspecific “others.” ACMA guidelines focus on utilization measures and quantitative output via statistical data.
CCMC and CSMA Codes of Practice are the primary instruments for triangulation in this qualitative research because of their focus on ethical conduct within the nursing process.
The CCMC and its respective professional organization, CSMA, provide Codes of
Practice stating eight basic and essential activities for case managers that reflect the core of the nursing problem-solving process which are assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general (CCMC, 2005). Core components of case management basic knowledge include case management concepts, case management principles and strategies, psychosocial and support systems, health care reimbursement, and vocational concepts and strategies (CCMC, 2015). CSMA performance indicators include guidelines for giving direction for education and training; identifying quality of care; collaboration with patients and providers; and legal, ethical, and advocacy considerations for case management practice, resource management and stewardship, educational preparation and certification licensure, and specific training
(CSMA, 2010). 60
The CCMC limits the certification exam to qualifying case managers to be case managers with a minimum of two years of experience under the leadership of a case manager related to the health needs of target populations. Utilization review or discharge planning job descriptions alone do not qualify. After passing exams, the board-certified case manager (CCM) abides by eight principles and six rules of conduct essentially mandating public service above personal interest, respect toward client objectivity, integrity, and fidelity with all customers (CCMC Code, 2015, p. 3). CCMC identifies a
Triple Aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (CCMC, 2015, p. 4). The certified case manager is held to sophisticated and broader performance standards than newly hired case managers including advocacy expertise, guarding against unnecessary harm, striving to meet ethical and legal responsibilities, promoting autonomy (Sminkey & LeDoux,
2016, pp. 194-197). Patient advocacy is paramount regardless of the payer source of the case manager’s salary. Potential for conflicts of interest are ubiquitous.
RN-CCM scope of practice. This project focuses on the nurse case manager who has achieved certification and is employed in an acute-care hospital setting. The hospital case manager is often, but not exclusively, the one to inform patients in detail on the impact of chronic or devastating illness and decision-making about treatments based on quality of life and affordability. Case managers are also employed by hospitals, insurance companies, high-cost pharmaceutical companies, and other providers and are the essential cost-efficient planning coordinator, communicator, and advocate in addition to the 61 delegated employee responsible for collecting and submitting data in measuring the effectiveness of operational clinical resource management.
The RN-CCMs scope of practice embeds competency in problem-solving and communication of critical details regardless of the problem being labeled ethical or practical. The scope of practice defining the RN-CCM has been defined extensively in literature (Powell, 2008, Treiger & Funk, 2016). RN-CCM ethical competency is “hard to define” (Taylor, 2005, p. 362) yet ethical decision-making is pervasive in the RN-CCM scope of practice (Banja, 2008; Moffat, 2014; Taylor, 2005). Ethically sound, competent, and effective RN-CCM professionals’ problem-solving skills consistently demonstrate a) accurate knowledge about health-care system protocols, compliance, and utilization of services, b) efficient clinical resource management based on clinical experience (Banja,
2008), and c) critical thinking in evidence-based practice (Stanton & MacRobert, 2007) including ethical decision-making supported by social values and professional codes of conduct (Banja, 2008). Equally important are individualized qualities informing ethics of caring advocacy (Taylor, C. 1995). Manifesting competency in compassionate empathy and emotional intelligence will vary among all people. Competency is based on others’ expectations that the RN-CCM adheres to industry compliance regulations and interpretations of ethical codes of conduct in communicating patient status for access to benefits.
Despite inequities and hidden agendas of various powerful and authoritative stakeholders, the RN-CCM has always been expected to maintain professional codes of conduct, be impartial, and consistently perform job duties. The Commission for Case 62
Managers administering a certification exam for experienced case managers defines the role thusly:
The ethically supported practice of case management is a professional and
collaborative process that assesses, plans, implements, coordinates, monitors, and
evaluates the options and services required to meet an individual’s health needs. It
uses communication and available resources to promote health, quality, and cost-
effective outcomes (CCMS reviesed Code of Conduct, January 2016).
The Commission further specifies the role within ethical issues to be:
Because case management exists in an environment that may look to it to solve or
resolve various problems in the health care delivery and payer systems, case
managers may often confront ethical dilemmas. Case managers must abide by the
Code as well as by the professional code of ethics for their specific professional
discipline for guidance and support in the resolution of these conflicts (CCMS
reviesed Code of Conduct, January 2016).
RN-CCMs assess, problem-solve given available resources, and devise solutions to reconcile financial constraints, regulation compliance, clinical protocols, patient autonomy, and internal perceptions of contributing to a moral life and performing as competent employee. Also, As part of the RN-CCMs maintaining expertise, re- certification requires accruing continuing education credits relevant to case management
(CMSA, 2010).
As the context of health care has changed, problem-solving has become more complex. Issues surface among competing priorities including the web of government 63 regulations; financial interests (and conflicts) of the health-care institutions, insurance companies and clinical treatment options; multidisciplinary providers, including physicians; and patient rights of informed consent and autonomy. As health-care costs increase and clinical services become more sophisticated, payers commonly respond with elaborate and impermanent pre-approval regulations, coverage exclusions, and network- limited utilization of services. This complex system in acute care created the need for a collaborator, the RN-CCM, who is vetted to have adequate resources to interconnect ethical views of financial, clinical, and professional priorities.
The RN-CCM is now essential in the oversight of high-risk or chronically ill patients. These patients may need professional services to prevent deterioration or may be in a hospital bed and not be receiving reimbursable care. The hospital now relies on the
RN-CCM to assess ethically sound judgements. The RN-CCM is burdened by changing staffing patterns established by organizational metrics; the relentless increase in regulations and pre-approval criteria; and advances in medical treatment that benefit the patient with more precision, creating shorter lengths of stay and allowing payers to deny inpatient bundled reimbursements (flat rate versus more itemized outpatient services).
Understanding the historical context of this professional role provides a view into health- care industry dynamics in general.
Summary
Highlighted literature in this section present dominant influences of health care conflicts requiring timely and competent problem-solving including ethics, personal attributes, and context. Principles of biomedical ethics support codes of conduct. 64
Empathy and emotional intelligence are human capacities contributing meaning-making to these phenomena of conflicts and the choices made in problem-solving processes with the context of a complex evolving health-care system. If problem-solving ethical or practical conflicts are unsatisfying based on one’s matured knowledge and attributes at the time, then a risk of moral distress develops. Historical events also inform health-care practices due to changes in technology, business arrangements, and public service, and consequently have had an influence on how conflicts are created and managed. Variables continuously emerge requiring interpretation of ethical principles and commensurate actions. The case management scope of practice requires insight and abilities to judge and advocate within a prescribed scope of practice for available and ethically integrated outcomes. Chapter 2 presents a methodological framework and research design to support qualitative inquiry on how RN-CCMs live their experiences based on these theoretical and historical frameworks. 65
Chapter Three: Methodology
This chapter introduces the development and purpose of phenomenological theory as it informs interpretive phenomenology research design, including the use of the researcher as the research tool, data collection, and analysis. This chapter discusses the historical framework and appropriateness of phenomenology theory for this study of reflections of lived experiences. Phenomenological methodology techniques are established that align with the purpose of investigating how RN-CCMs experience daily interactions. Data collection procedure and analysis as selected and presented are standard interpretive phenomenological methodology. The purpose of this chapter is to explain the intention and process of data collection.
Historical Evolution of Phenomenology Philosophy
Kant (1724-1804) and Hegel (1770-1831) primarily are credited with the first description of phenomenology as a philosophical paradigm. “Franz Bretano (1838-1917) employed the phrase ‘descriptive psychology or descriptive phenomenology’ that inspired Husserl’s (1859-1938) development of phenomenology as a philosophy for research” (Dowling, 2005, p. 131). Phenomenology emerged as a valid social science research theory by Husserl in the post-World War II era of failed predeterminate positivistic research theory assumptions that reality had one authentic explanation
(Harvey, 1989). Husserl approached qualitative research as descriptive; his predecessor
Heidegger had a more interpretive view of the lived experience. Subsequent philosophers described interpretive phenomenology (hermeneutics) philosophy “as a way of returning to and exploring the reality of life and living and describing phenomena as they appear to 66 the person experiencing the phenomena” (Tuohy, Cooney, Dowling, Murphy, &
Sixsmith, 2013, p.18). The hermeneutic approach in the social sciences views human action from an interpretive perspective as context bound and, consequently, maintains that “the meaning of a particular human action has to be interpreted in much the same way that a particular passage of text has to be interpreted (i.e., in its particular context)”
(Kurtines, 1987, p. 785)
Phenomenology, which has become a credible philosophical foundation for studying human consciousness (Heinomen, 2015, p. 31), is primarily a philosophical method of questioning; not creating theory” (Van Manen, 2014, p. 50) and “not a method for answering, discovering or drawing determinate conclusions” (Heinonen, 2015, p. 35).
Ravich and Riggen (2017) observe that
coupling a phenomenological perspective with an ecological system affords a
more dynamic, culturally responsive, context-sensitive perspective for
interpreting the individual’s own meaning making process…and captures the
individual’s inter-subjectivity. Behavior [derived from meaning making] has
outcomes and consequences for the individual but at the same time it also affects
other people, and thus alters the environment in which sense making and identity
formation occur (pp. 143-151).
The challenge in current phenomenological research is not in the philosophical foundations legitimizing this approach to discovery, but in the approach to methodology. 67
Research Design
This qualitative phenomenological research proposes, within the phenomenological framework described, to synthesize the aggregated experiences of a homogenous sampling of a subgroup called Certified Nurse Case Managers (RN-CCM) in a social context (acute-care hospitals) to reveal the essence of a shared reality of lived experience phenomena signifying conflict, empathy, problem-solving, and self-care. The researcher seeks to explore the phenomenon of conflict (particularly ethical dissonance) in the context of health-care delivery processes, and the RN-CCMs’ lived experiences when advocating for patients in the context of compelling and mundane problem-solving experiences reflecting implicit or perceived ethical codes of conduct and practice among financial, clinical, and personally meaningful priorities.
Qualitative phenomenological theory offers a venue to explore the psychology forming social conditions. “Psychological processes are irreducibly relational in that they meaningfully illuminate the person’s world, including experiences in the same or other persons’ mental lives” (Wertz, 2011, p. 126). This process of “intuition of essences” or
“eidetic analysis” opens up complexity, and aims to clarify all that human beings live through in a particular kind of phenomena (cf. Wertz, 2011).
The theory of phenomenology informs and supports an interpretivist framework as a methodology for humanistic research. Heidegger believed individuals’ descriptions of life world are perceptions to be described as phenomena. “Descriptive (eidetic) phenomenology is to describe a phenomenon’s general characteristics rather than the individual’s experiences” (Giorgi, 2008). Giorgi’s (2008) phenomenological 68 methodology (DRPM) supports an interpretivist phenomenological framework for a researcher to go beyond isolated experiences but does not extend to interpreting themes before they hatch. Time and space are important concepts in interpretative phenomenological study (Tuohy et al., p. 18); this inclusion distances descriptive from interpretivist methodology procedures. Van Manen’s interpretivist (hermeneutical) analysis from which an understanding emerges by “a circular process of continuous re- examination of propositions” (Tuohy et al., 2012, p. 20). Interpretivist phenomenological procedures include formulating questions about a function of something deeply human and conducting thematic analysis of the lived experiences by vetting transcriptions for consistency or variations of meaning through reduction (Fain, 2004; Giorgi, 2008;
Heinonen, 2015). Qualitative phenomenological narratives begin relevant exploration about the conditions creating conflicts for RN-CCMs.
Interpretive Phenomenological Methodology
Focusing specifically on psychological phenomenological approaches, Finlay asserts that four core characteristics hold across all variations in qualitative methodology
1. the research is rigorously descriptive,
2. uses the phenomenological reductions,
3. explores the intentional relationship between persons and situations, and
4. discloses the essences, or structures, of meaning immanent in human
experiences through the use of imaginative variation (Finlay, 2009). 69
This framework is suited to comprehending and puzzling out the depth and breadth of the participants’ lived experiences in scenarios of real-world phenomena (not hypothetical sampling).
Qualitative methodology is suited for uncovering social conflicts and problems
that projects attempting to change health systems often meet. They provide data
which may be valuable in the motivation and education of the professions
involved in the health service systems (Holm, L. & Smidt, S., 1997, p. 373).
The intent of interpretive phenomenology (hermeneutics) is to “describe, understand and interpret participants’ experiences” (Tuohy, Cooney, Dowling, Murphy,
Sixsmith, 2013, p. 18) and goes beyond Husserl’s model of description only. Interpretive phenomenology’s applicability for understanding elements includes the idea of life world, an existential theme, according to Van Manen, used to describe the concept of “how people live in and experience the world: Lived space, lived time, lived body and lived human relation” (Tuohy et al, 2013, p. 19).
Each participant in a situation comes with his or her own set of reasons for action-
interaction, and rarely does each person have a grasp of the whole situation. It
takes listening to many voices to gain understanding of the whole (Corbin &
Strauss, 2015, p. 162).
Qualitative phenomenological methodology that focuses on organizational processes looks “at the essential character or nature of something, not the quantity”
(Roberts, 2010, p. 143). Common life world experiences labeled “conflict” in the context of hospitals are complex and vulnerable to different interpretation and meaning. The 70 focus of this qualitative phenomenological methodology research is “epistemological considerations focusing exclusively on the meaning-making activity of the individual mind” (Patton, 2013, p. 97). It can be assumed that RN-CCNs’ responses describing life world are likely to vary regarding what, how, and when the meaning of circumstances are defined as conflict, how problem-solving and meaning-making are created, and the key outcomes of assimilating the meaning, accommodating or mitigating non-congruent outcomes (rituals, performance, vacating job). This qualitative reflective phenomenology methodology focuses on reported lived experiences including empathy, decision-making
(and its meaning), and modalities of self-care experienced by the participants.
Saturation is a concept assigned to data collection that contains sufficient and thick description, not necessarily exhausted amounts of data, and is sufficient to glean what Van Manen (2014) refers to as the “phenomenology of practice as research and writing that reflects on and in practice and serves to foster and strengthen an embodied ontology, epistemology and axiology of thoughtful and tactful action” (p. 18). To honor these intentions, Van Manen endorses Jean Luc Marion’s ideas that qualitative saturation is unrealistic and that conversational inquiry can somehow be limited in describing the human experience. Saturated phenomena are not an expectation of qualitative technique of data saturation: “Some human phenomena are so saturated with excess meaning and intuition that an eidetic or originary phenomena is not really possible [by means of reduction] ... some saturated phenomena may be invisible, such as the latent meaning of an ‘event’ that will show itself later in life” (Van Manen, M., Higgins, I, & Van Der Reit,
2016, p. 5). Narrative interviews for this study are reflective. Saturated data will be a mix 71 of remembering events and the phenomenology of practice for the participant. This approach supports the reflective narrative and idea that emerging themes identified through reduction will not exhaust individual meaning made for each phenomenon described.
Tools of Research
In phenomenological research design, the researcher is the instrument, replacing the intake provided by a quantitative tool. The researcher as research tool employs two essential interpretive phenomenological methodologies: epoché and bracketing and reduction [also called condensing] (Wertz, 2011, pp. 125-126).
Epoché sets the intention to engage in the interview as a blank page and dissociate personal bias and expectations. Moustakas defines epoché as a methodology to refrain from judgment, to abstain from or stay away from an everyday, ordinary way of perceiving things. Epoché requires that we learn to see what stands before our eyes.
When understandings, judgments and knowings are set aside the phenomena are
revisited, freshly, naively for the vantage point of a pure or transcendental
ego…each experience is considered in its singularity” (Moustakas, 1994, p. 33-
34).
Epoché sets a blank page; bracketing places aside the interviewer’s bias and personal perceptions of the topics under discussion, which is essential to be present with the object essence emoted through the participant’s narratives. Bracketing out bias and anecdotal mental processes during participants’ responses gives the interviewer the 72 ability to understand the lived experience being described. In Finlay’s view, within interpretivist phenomenology
bracketing the researcher’s previous understanding and knowledge fore-meaning
and prejudice helps interpretation…bracketing is understood as recognizing what
has influenced our understanding and view of the world. Rather than setting this
aside we need to bring it to the fore to be recognized as influences and biases [in
order] to be open to other people’s meaning (Finlay, 2009, p. 13).
The interviewer collects data using skills of observations both about the interviewees’ responses and the researcher’s internal responses in order to understand the lived experience being offered in verbal and nonverbal responses of the other—in this case another peer professional.
In addition to epoché and bracketing, research elements establishing trustworthiness include naturalistic inquiry, empathic neutrality, and the participants’ assumed assurance in the sponsored interviewer’s integrity and knowledge of the job; they also are the scaffolding for reliability and trustworthiness of data and subsequent analysis of phenomena embedded in participants’ contributions. Phenomenological themes are revealed by these intentional actions.
Naturalistic inquiry “puts one in close contact with people and their problems”
(Patton, 2002, p. 50). The real-world settings are not manipulated (Roberts, p. 143).
Empathic neutrality, a qualitative research skill, is judicial (Duffy, 2010, p. 49) and is the intention to create an atmosphere of unbiased curiosity and listening. In fact, nursing requires this as professional development. 73
Establishing trustworthiness and reliability of collected data answers the questions, “Can persons believe the results of this study? Are the data reasonable?” (Fain,
2004, p. 198). The perceptions described by the participants are the data; different experiences of the same job title do not make either invalid. Credibility of the interviewees is also supported by consideration of the researcher’s trustworthiness.
Absent triangulation options, Fain (p. 198) identifies two contributing facts to establish trustworthiness or credibility of the data: [First,] established prolonged engagement of peer connections facilitating access to participants and [second,] the robust administrative background of the participant researcher.
Four participants had been previous employees with whom I worked and assisted in their duties. I had observed their problem-solving in the front end for several years; their work ethics and professional actions were impeccable based on their supervisor evaluations. Two other participants were professional colleagues whom I had encountered at professional meetings and who have held case management leadership roles locally and nationwide. Five of the six participants volunteered readily when approached by the intermediary; the sixth was the intermediary whom I contacted through an administrative manager and friend. The remaining two participants first met me at a professional peer organization. The organization president vetted my cold call request to seek volunteers at the local educational meeting. These two participants did not have a prolonged history of engagement with me personally. Their leadership’s endorsement and my background, which included my nursing school and employment in
Ohio in hospitals familiar to them, combined to established probable credibility and 74 trustworthiness as a peer and researcher. In summary, credible findings are supported by prolonged engagement with participants and the researcher’s extensive professional experience and involvement with the case management role, thereby establishing the participant observer as research instrument.
In addition, congruent experiences of phenomena described in the participants’ reflections and observed by the participant interviewer were reconciled with other credible sources (e.g. Professional Codes of Practice for Certified Case Managers).
Corroborating evidence from different sources shed[s] light on a theme or perspective
(Creswell & Creswell, 2013, p. 251). The researcher’s potential blind spots are revealed and establish the trustworthiness of the data analysis and reliability of emerging themes.
The competent qualitative researcher is also self-aware and reflexive in ongoing self-examination (Patton, p. 64), conducts constant comparisons to identify one’s own perspective and other, uses metaphors, divines meaning from linguistics of the participant, and makes use of life experiences to probe without putting words in the mouth of the participant. Probing questions emerge when observing, embracing, and observing the interviewees’ chosen experiences to be reflectively described. In this phenomenological methodology paradigm, qualitative inquiry provides opportunities to achieve empathy and give the researcher an empirical basis for describing the perspectives of others (Patton, p. 53). Reduction is a method applied to the experience being described “to bring together aspects of meaning that belong to the phenomena of our life-world and the phenomena being discovered in the description” (Heinonen, p. 36). 75
The benefit of assigning the researcher as the intake tool in this research project is to inform others about how RN-CCMs manifest human perceptions and responses—in this case, how each case manager’s personal attributes may influence the perceptions, experiences, and meaning in the phenomena of ethical conflicts. With this information more effective mentoring, training, and prevention can occur.
Data Collection
Purposeful sampling of this homogenous group allowed for small sample size and depended upon emerging theme redundancy identified among participants. Qualifying participants were hospital certified nurse case managers with at least three years of experience in a case management role. The researcher recruited case manager participants through professional organizations (local professional organization in Ohio and informally through peers in Massachusetts. Age, specialty, years of nursing experience before certification, and education were not limitations. Of note but unrelated to the set criteria is that all had been nurses for at least twenty years. Each person is a member of their local Case Manager Society of America chapter (CSMA) although involvement with CSMA varied from past president to sometime attendees at continuing education presentations.
Eight interviews with the RN-CCM’s lasted 45 minutes, one lasted 90 minutes and all were conducted based on participant’s availability, choice of location and convenience. Four interviews were conducted in work site offices after the workday of the interviewees, three were in a private home of one of the participants on a weekend, and one was in a coffee shop after the business day. 76
A semistructured interview format allowed the researcher to guide the conversation. Probes were used when the researcher determined that additional information related to the topic and reflective descriptions might yield more data.
Through semi-structured reflective interviews and preparing thick descriptions and coding themes, the interviewer (researcher) puzzled together “words, actions, behaviors and interpersonal interactions as data to yield the participants knowledge, opinions, perceptions, and feelings” (Roberts, p. 143) and meaning in describing phenomena of lived experiences. Common emerging themes were identified across the interviews of all participants. This was accomplished through a condensing or reduction process of transcribed responses, field note observations and personal journaling of the interview experience. An elaboration of this process is described below in more detail.
Data Analysis
“Giorgi (1997)… argues that the phenomenological methodology encompasses three interlocking steps are 1. Phenomenological reduction, 2. Description, and 3. Search for essences …or structures, of meaning immanent in human experiences through the use of imaginative variation” (p. 235). The confidential interviews for this study were recorded, transcribed, and coded according to the process described by Saldana (2013). In the first cycle the researcher “divides the original processes of the interview into subcategories. …[The second cycle requires] analytic skills [in a phase of] classifying, prioritizing, integrating, synthesizing, abstracting and conceptualizing cycle one work into themes” (p. 59). The emerging themes through reduction of individual perceptions 77 about problem-solving and conflicts. The intention behind this coding process defines interpretive phenomenological methodology.
In phenomenological research the most powerful tool in data analysis is the researcher. Therefore, to understand the process of data analysis, the researcher seeks to understand, describe, and probe the descriptions offered by the participant without any intention to persuade or alter information offered. In Phenomenological Research
Methods (1994), Moustakas describes a strategy of the investigator to conjure a kind of empathic experience of the participant. “Analysis is intuitive and requires trusting the self to make the right decisions” (Strauss and Corbin, 2015, p. 92). Reality embeds alterity
(self vs. other) so “empathy of the other is an intentional category” (Moustakas, p. 37) for the researcher’s apprehension of other. Based on this imagined state, the researcher asks questions and records the answers by applying a “transcendental process to understand something that is not ‘my own’” (p. 37). Phenomenological qualitative interpretive analysis processes originally described by Giorgi (2008) describe the researcher’s nine- step process (p. 38-39). In short this process includes the researcher reading the entire transcript to glean a sense of the whole. To reach a sense of the whole involves
1. reading the transcript again slowly,
2. delineating each time a transition and relatable meaning about the phenomena
is perceived,
3. eliminating redundancies
4. clarifying meaning to the researcher 78
5. reflecting on given units for concrete language and continues with the essence
of the situation for the participant being transformed into language used in
psychological science, and finally integrates insights into a consistent
description of the whole (Giorgi, 1997, p. 83).
The interpretive process creates “understanding of the meaningful concrete relations implicit in the original descriptions of experience in the context of a particular situation as the primary target of phenomenological knowledge” (Moustakas, 1994, p.
14). Qualitative phenomenological methods are not empirical because no theory or explanations are offered, only descriptions and interpretations.
Constant reflection during interviews by the researcher will inform inter- subjectivity and guide the analysis process. A coding system will evolve during transcription evaluation to identify significant indicators of the lived experience identified by the participants when answering semistructured questions. The coding to identify themes arising from interview content and behavioral cues will be reduced to general themes emerging from descriptions of the lived experience.
Constructs of coding are informed by phenomenology motivated to discover meaning-making implied or stated in the offered narratives. Heppner and Heppner (2004) established stages of creating definitions of domains, core ideas in meaning-making, audit of core ideas, and cross-analysis (p. 166). Saldana (2013) describes the coding process in qualitative research as cycles of inductive thinking to generate the analysis and themes. Saldana refers to three cycles of coding; each cycle connects themes and analyzes transcripts and analytic memos to determine the lived experience of the 79 phenomena being studied. Initially considered concepts are causation axial, affective, focused, and values and versus evaluation coding structures. By theming the data for extended phrases or units of data, meaning is gleaned for transcripts and analytic notes.
Accomplishing depth of meaning requires preparing analytic memos during and immediately after the interview, in the first cycle, after first cycle, in the second cycle, and after second cycle coding. Necessary personal attributes for coding include organization, perseverance, ability to deal with ambiguity, flexibility, creativity, rigorous ethics, and a command of vocabulary (p. 36-37).
Wertz (2011) shows how themes emerge from qualitative coding of transcriptions in phenomenological methodology coding as a progressive analysis, starting with assigning interpretation of behaviors such as tone and affect to categories which are then assigned to themes related to the experience. To illustrate, Wertz uses an article about a nurse describing an event involving ethical conflicts that occurred when staffing was marginally safe. The interviewed nurse commented “two junior RNS in CCU, but that’s all there was [which the author] inducted to represent the themes of 1. sense of powerlessness, 2. inadequacy of staffing-particularly level of expertise” (Sundin-Huard &
Fahy, 1999, p. 10).
Ultimately, creating core ideas, themes, and analytic strategies is the prerogative of the researcher based on the researcher’s held philosophy about how society is perceived through a phenomenological lens. This creative aspect of qualitative research provides inductive opportunities for the investigator to promote trustworthiness and 80 reliability because they are based on established frameworks and theories about real and ordinary lived experiences.
Phenomenological coding methodology requires social science perspectives and construction for analysis. The phenomenological approach relies on intentionality, intuition, and intersubjectivity, none of which lend themselves to predetermined coding categories such as are listed in Saldana (2013) in the appendix. Sundin-Huard and Fahey offer themes related to moral distress to include life-threatening illness, conflicting legal and moral obligations, perceived inappropriate medical treatment, aggressive communication style, and avoiding criticism and shame (p. 10).
Self as Researcher: Disclosure
My nursing experience started with graduation from a diploma program in 1975, just as DRGs were introduced. Until 1992 I worked in a variety of acute and nonacute settings, including as a medical malpractice paralegal and research assistant. My tenure as a case manager began in 1995 with Blue Cross Blue Shield in an oversight role for catastrophic case clinical utilization. I became a certified case manager after passing an exam which required, among other prerequisites, two full years of employment as a case manager. In 2011, I took an additional certification for Case Management Administrator
Certified (CMAC), an advanced level indicating knowledge of at-risk populations, clinical systems, organizational culture, human resource management, and outcomes measurements.
From 1997 to 2012 I was a manager of compliance and insurance liaison support within a department of care coordination in a large teaching hospital in Boston. For 15 81 years I witnessed and experienced increasing scrutiny of the case manager’s authority to act as a self-directed advocate within a complex health-care system with significant influence on how clinical resources are allocated, defined, and inconsistently applied among patients. This personal experience offers an insight uncommon to those outside the profession. Another contributing factor is long-term professional relationships with six of the eight participants. My association involved professional organization events and daily work encounters. I had not spoken to any of these participants since leaving my position in 2010. However, my having been embedded in daily operations for years brought a trust that contributed to credibility in the interview.
Credibility developed through years of direct contact matters, and yet bracketing as defined earlier is possible because in reality every case manager has a different background of experiences coming into the role and under various specialties. Authentic discovery was possible in my experience of the interviewees as they described experiences. My background could facilitate the interview in that rigorous probing questions focused on what may not be said and only apparent to someone who has direct exposure to migrating clinical and organizational priorities. Nevertheless, to honor the epistemological nature of phenomenological methodology, a vigilant approach to bracketing personal opinions and creating leading probes was successful based on the rich data. Limiting personal opinions when actively listening to patient histories is expected in health care professionalism, including nursing.
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Chapter Four: Those Who Care: Reflections of RN-CCMs
This chapter offers working biographies of the eight participants, including selection processes, group demographics, and individual excerpts of meaningful experiences. The overview of the group and person-specific excerpts serve two purposes.
First, they introduce the participants’ variable responsibilities and work sites as they were perceived the day of the interview; second, they address two of the research questions:
“How do the experiences of decision-making change RN-CCM’s lives?” and “What influences RN-CCMs’ decision-making processes?” The interviews reveal everyday RN-
CCMs’ choices on how to advocate and solve problems. These choices are based on knowledge of clinical implications for and empathic maturity toward those less financially secure, educated, or capable of self-advocacy. The problem-solving process is affected by a trend in health care to restrict the scope of practice and broaden rosters of patients being followed. This trend is evidenced by an increasing installment of protocols focused on large groups of high-risk populations. Restricted access to benefits, social obstacles to care, and cost-containment initiatives also are embedded in these participants’ reflections.
Finding RN-CCMs to Participate
Participants worked in two different states and in different hospital network locations. Case management populations in Ohio and Massachusetts were recruited because of researcher accessibility. Consistent with the IRB approval, volunteers were found using two methods. In the first method, an email and follow-up call to the leadership head of an Ohio Case Management Society of America chapter resulted in an 83 invitation to announce my project during a semi-annual networking dinner and continuing education presentation program in November 2016. At this professional meeting two volunteers consented to be contacted. The remaining six volunteers were approached through a more informal process. I had lunch with a professional acquaintance in Massachusetts with whom I had previously worked; she suggested I contact a mutual RN-CCM colleague. The colleague to whom I was referred enthusiastically volunteered to be an intermediary by setting up interviews during a long weekend in November. In all circumstances, at the time of interviews each person met the criteria of being an RN-CCM in a position funded by a hospital network. Assignments ranged from acute-care inpatient setting to a hospital-affiliated provider located in an off- site building. Geographical variances did not impact pre-established criteria for participants; in fact, this variable added more context to the RN-CCM specialty areas and hospital networks represented as summarized in the next paragraph.
Being an RN-CCM: Attributes, Self-Care, and Work Interactions
Attributes. Participants were mature professional caretakers with advanced degrees; all work in large urban hospital networks providing a broad range of services from acute-care inpatient to non-acute outpatient care oversight. One individual had an
RN diploma-level education and master’s in business administration; four participants held bachelor of science in nursing degrees; and the remaining three were master’s prepared either in nursing (two) or health care administration (one). Every participant had more than 25 years of nursing experience; five had more than 30 years’ experience.
Certified case manager tenure varied. Minimum requirements to sit for the case 84 management certification exam include work supervision by an RN-CCM and at least two years of experience of full-time employment providing case management services.
Professional longevity and advancing professional practice demonstrate adherence to standards of ethical practices informed by codes of conduct in health care environments.
Two participants took the first exam offered in 1992; one took the exam in 2014. At the time of these interviews, the range of experience as a case manager (CM) was 12 to 30 years and 2 to 27 years as a certified case manager (CCM). Table 4.1 summarizes the participants’ background details.
85
Table 4.1.
Demographic and Professional Experience Characteristics of Certified Nurse Case
Manager Participants in Order of Presentation
Highest Yrs. as Yrs. Yrs. Nursing Current Initials Age Gender Education RN as CM Certified Background Specialty
Generalist; consultant; Tertiary BH 60s M MSN ’94 >30 30 27 managed care hospital float insurance
Inpatient rehab; Diploma nonacute Tertiary CM 60s F RN; MSHA* 20-30 27 27 screener; hospital float ’97 insurance; workers' comp
Population HR 50s F BSN ’83 >30 25 20 Worker’s comp health
Cardiac-surg.; Women’s MJ 40s F MSN ’14 20-30 20 19 workers' comp; health, gyn home care oncology
Cardiac Tertiary KF 50s F BSN ’14 >30 27 15 telemetry hospital float
Med-surg; Diploma Manager of emergency PN 60s F RN; MBA >30 20 13 population room; ’09 health administration
Obstetrics; public health; Population JG 50s F BSN ’84 >30 21 2 oncology; med- health surg
Pediatrics; Population MC 50s F BSN ’97 >30 12 2 neurology health Note. Licensed RNs are graduates of 2- 4-year training programs and often seek additional training part-time while employed as RNs. * Masters in Health Administration. 86
Self-care. Each RN-CCM described self-care activities as personally meaningful activities. In 2015, identifying the meaningfulness of self-care to the profession, the
American Nurse Association published a revised code of ethics in which included
Article Five: “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth”
(Lachman, Swanson, & Winland-Brown, 2015, p. 364). RN-CCMs reflect this new guideline in the following examples of engaging in unique hobbies and fulfilling choices such as travel or art as counterbalance to depleting experiences on the job; physical activity away from desk; and withdrawing from or avoiding confrontational conversations with hierarchy concerning business protocols. These self-care activities align with personal values and moral actions.
Participants were asked three times about self-care as follows; a) at the beginning to identify meaningful hobbies b) midway through to identify coping skills on and off the job, and c) near the end of the interview when asked to reflect on the value of certification. Hobbies ranged from the sedentary to the physically challenging. Coping skills on and off the job site revealed as having value and meaning included professional peer support and knowing when to take a break.
When revealing hobbies, RN-CCM responses described categories of self-care to be physical activities such as golfing, stair climbing, and kickboxing; creative activities such as collecting personally meaningful artwork; repetitive projects like sewing; and others including equine care time with daughter and self, vacationing, reading, and 87 cooking. Additional activities related to work included consulting informally in person or through texting with peers, confiding emotional concerns to partners, seeking consulting contracts, booking occasional massages, engaging in public policy committees advocating for case management, and taking vacations. Certification was viewed as an action characterized as self-care for professional purposes and is highlighted in chapter five as an unexpected finding.
Work interactions. RN-CCM duties included following protocols, interacting with patients briefly or over time, and preventing high-cost complications through ethically sound and meaningful interventions. Two participants are involved in outpatient obstetric or pediatric high-risk populations; the remaining six specialized in adult population (two outpatient, four inpatient). All four outpatient RN-CCM caseloads were identified as high-risk for a variety of reasons, including pay-for-performance metrics.
Three were given rosters; one found high-risk patients from emergency census sheets or peer recommendations. Two outpatient RN-CCMs (MC, HR) engaged in patient interventions daily, mostly by telephone; one was a mentoring/manager for newly hired case managers. Of the four inpatient RN-CCMs, 1 was assigned to a permanent team and
3 were floats with a considerable variety of work assignments within the acute-care setting.
Themes of conflicts emerged in each job description due to unavoidable and significant changes, empathy as described in chapter two, and problem-solving unique in the case management scope of practice. These findings will be discussed further under emergent themes in chapter five with additional interview excerpts. 88
RN-CCMs Working Biographies: How We See What We Do
Working biographies are organized by longest duration as a certified case manager. Each participant’s biography includes an introduction of current working context, relevant historical context for initial employment performing case management duties, personal attributes noted on initial presentation and during the interview, and volunteered self-care activities. Reflective verbatim narratives of unique work experiences follow these details. This chapter highlights each RN-CCM’s unique scope of practice focused on containing hospital network costs, aligning with clinical practice guidelines, and advocating for ethical care plans and patient autonomy.
In the excerpts below, each RN-CCM describes a scope of practice that includes ethical and practical dilemmas requiring clinical knowledge and empathic maturity to resolve. Each RN-CCM implicitly expects tasks to be completed accurately and on time as moral actions of autonomy and trustworthiness; refers to collaborating on tasks that require effective relationships and demonstrates conduct of benevolence and non- maleficence. RN-CCMs volunteer actions of advocacy requiring expertise in all four ethical principles defined in chapter two. Alignment of chapter two theories with narratives are presented throughout.
Ben Harris (BH): Inspiring advocacy by expecting better patient outcomes.
The last participant interviewed had the most expansive work history and the most insight on changes in the profession over time. BH volunteered for this interview when requested by a professional peer. BH and I were professional acquaintances through the CSMA network and had not been in contact for several years. The interview was scheduled at his 89 convenience in his home on a weekend midmorning. His two-story waterfront townhome was brick with several doorway entrances. I knocked and he walked down the entrance stairs with a smile and welcoming comments. The walls were off-white from ceiling to floor, with carefully orchestrated arrangements of dozens of original pieces of artwork, eclectic in themes and styles. The sun entered the living room from large French doors, beyond which was a deck overlooking the harbor. The space had loose papers on the dining room table, magazines and books around—generally a cozy nest feel.
For this interview BH was dressed in casual home clothes. He wore slippers. He spoke clearly, listened to questions with intense eye contact, and was consistently animated with a sense of humor about perceptions of ironic conditions at work and meaningful roles in his personal life. He is the only male interviewee; male nurses are a minority and case manager males even more so. Gender may be an implicit source of power and male privilege in negotiating and problem-solving in the following narratives.
BH is a committed patient advocate. BH’s considerable accomplishments and contributions to the profession through articles, professional organization leadership roles, and conference lectures have required due diligence. The credibility of his narratives was based on his lived experiences, his trust in me as case management peer, and his motivations to identify and make known ethically challenging issues in health care observed over the years. BH obtained a master’s degree in health care administration in 1994 and his CCM in 1994. He recently obtained the case management certification offered by the ANCC. He is professionally active in nursing organizations. He has served on CSMA’s board of directors. 90
Now in his 60s, BH has had a professional career in case management spreading across thirty years. His career began in 1984 a few years after he graduated with a BSN and had some work experience. At the time managed care companies were almost nonexistent; fee for service was the reimbursement system and insurance was provided through employers. DRGs determined a reasonable length of stay. If you were in a hospital, your care was acute level. This process has significantly changed over the years, creating conflict among health-care agencies. BH began by describing his history of his professional nursing practice in the following statement.
I have done hospital and managed care consulting, industry relations with
pharmaceuticals, DME companies, even some employer groups teaching …what
they should look for in terms of case management services for their employees....
The consultant piece I did on my own so it wasn’t as an employee (BH, personal
communication, December 3, 2016).
Here BH establishes an exemplary range of experiences as a case manager. With his exposure to varying environments in health care, BH knows how different groups of providers interpret ethical actions. Health-care interest groups do not all agree on where and how to provide care, which is why his background gives him a broad and deep appreciation of agendas concerning distributive justice.
The conversation then turned to job duties. BH mentioned that his primary role has reverted to prescribed discharge planning and utilization review. His position is float case manager duties defined below. 91
So, I’m a float. I work four tens [hour shifts] usually 8-6:30. As a float I never
know where I’m going to go, so it’s a matter of when you get there, you will be
assigned. We had more floats but currently we are trying—we have restructured
the floats that a lot of floats only rotate through certain floors so we now have a
cardiac float that they only go to the four floors they cover, there are people
working four tens and they cover the day off for all four of them. That sort of
makes sense, however, if someone is out sick on a leave 3 months and you are in
a position, you are there for a day, you get bumped for a day because that is her
position and then you are put back there for the other next 3 days. It’s because of
continuity. “OK” (laughing). It also decreased the flexibility of the number of
people that can float. There are only a few of us that can go everywhere. So that
my consistency on an assignment, I do think that consistency on my assignment,
like if someone went on vacation for a week, I would cover them for a week. You
get more traction if you follow yourself and you know the cases well and you are
a lot more effective. But because I go to ED, I go to Psych, I go to Pedi, I go to
Oncology, I go to Neuro if someone calls in sick, “Well, so-and-so can’t work
there so we are going to put them where you were yesterday and we are going to
put you there.” So, there is less consistency of care (BH, personal communication,
December 3, 2016).
In this narrative BH explains the constantly changing landscape of a float case manager. He describes variable and changing priorities over assignments and within the department. The float occupies a lower hierarchy within team coverage, therefore his 92 assignments can change daily even though he works consecutive days. His considers this to be a lack of continuity for patients, an ethical reflection of beneficence and non- maleficence. These ethical principles also surface in the next comment, as BH speaks with an edgy affect about his perception of current organizational pressures in directing patients’ choice in care planning:
I think the main focus now is the ACO [accountable care organization]. We have
moved from patient care to money focused. (pause) Well, part of the UM
[utilization management] piece. It’s also the case management piece. There is
huge pressure to move people to post-acute agencies within the ACO. Supposedly
with the ACO set up (pause) they [administrative contract staff] had criteria
stating [providers] had to have at least 3 Medicare stars…have good safety ratings
etc., etc., etc. Some of them currently have a one-star rating, they are still within
the organization and we are told we should be using them (BH, personal
communication, December 3, 2016).
This comment reflects the enormous shift in health-care systems. When BH began his career, he was able to recommend post-acute services based on the best fit for what the patient required. Today those services may or may not be provided at the network facility, and yet the case manager is told to refer patients there. The impact of financial and contractual obligations implies that financial obligations supercede best fit for the patient. BH perceives this situation as restricting advocacy and autonomy.
In addition to these types of ethical dilemmas are task-relationship dilemmas.
Many changes in task-relationship interactions have impacted BH’s scope of practice and 93 perception of job value. Examples include higher caseloads coupled with nonclinical support staff performing initial assessments; the function and pitfalls of computer-based communications and stored data when minutes count in retrieving information relevant to safe discharges; and the decrease in time with patients due to required communications and clearance with vendors and payers for approvals. Before health care became dependent on computer processing, BH would collaborate and bargain with outside vendors to take a challenging patient because they had taken several easy and insured patients. This type of collaboration vanished with computer link-ups to get electronic medical record data because fewer direct conversations occur on site or over the phone.
Lack of experience also contributes to the decrease in savvy coordinating of services.
Now obtaining approval for an out-of-network provider takes extra steps for the case manager, as illustrated in the following narrative:
A guy came down from Maine, northern Maine, right on the Canadian border,
dying, Med-flighted down, nothing we can do. Needs to get home, doesn’t have
ambulance transportation home, needs O2, needs to go to a facility, don’t know
the facility he is going to, try to get O2 vendors and get free oxygen because the
facility he is going to has to arrange for the oxygen. (pause) You are off the next
day and someone is covering for you and you find out she told him the ambulance
wouldn’t be covered, the family leaves the bed. Well, I got insurance to pay for it
the next day simply by calling the doctor’s office. “You know you med-flighted
him down, he’s dying, his birthday is Friday, today is Wednesday, he wants to be
in Maine for his celebration, his wife and his kids can’t come down.” I got it 94
covered but they didn’t know that (BH, personal communication, December 3,
2016).
BH’s extensive experience and ability to identify a compelling circumstance requiring resolution contributed to his successful intervention. In this case, task- relationship dilemma develops because of an implied inadequate expertise. BH’s intervention resolves the immediate problem but not the cause. Similarly, BH reflects on another story of equally compelling everyday scenarios within the acute case management setting:
Somebody else had [PIR HMO] and was a [SETAP] bus driver, bad head injury,
really needs 24/7 with the walking wounded. Sister’s in, going to Las Vegas. OK,
we will work on that. So, I come back the next day, someone who followed him
[said], “Oh she, the sister, [PIR] doesn’t have insurance coverage in Nevada. She
is looking at travel insurance.” (chuckling). So, I [say] “Well, travel insurance
isn’t going to cover pre-existing condition, A, and B, patient had a [PIR PPO]
product and as such would have a home care benefit using the [PIR] network.”
She didn’t know that. But we don’t educate our people except for orientation (BH,
personal communication, December 3, 2016).
For the bus driver needing family support out of the state, the case manager’s expertise and empathic maturity on the beneficence of family support is invaluable to patient advocacy. And in this third excerpt BH describes the processes of approvals for network and non-network providers: 95
Basically…we now have rules that all VNA referrals are supposed to go through a central [computerized] process [which makes] it more likely we will use an in- network ... owned agency. We can enter that ourselves and respond appropriately.
Out-of-network referrals we are supposed to send to a mailbox staffed by a nonclinical person who will then call the agencies and get back to us with an agency. [Before this protocol] I used to make one phone call, talk to the agency, give them the information, they accepted it. It was done. Now I need to put it into an email, send it to somebody who sends me back that they are taking care of it, their contact is such-and-such at the agency who will get back to me (pause). Two or three hours later I still don’t have an answer. So, I pick up the phone get an agency and it’s done. But I’m chastised for doing that because I’m not following the process. (Pause) The other issue is now that we are doing all this thing electronically, there are several other downsides that I am seeing to that. One, when I call in the referral myself they would ask me all the questions, they were answered, I was done. Now you put it in electronically, the referral person sends it to the agency, they send you back questions that you have to answer and you go back and forth. I don’t see is as a time saver at all. I think it’s extra time. That’s the other problem to it. We’ve taken away access in the institution for hospital- based vendors…we use to have vendors that were credentialed by the hospital so they could come in and they could access the medical record, pull out the medical record, see everything. We’ve taken away the role of outside vendors. The only 96
ones that are allowed access are the ones that we own (BH, personal
communication, December 3, 2016).
BH’s candid responses identify ongoing daily circumstances creating dilemmas and emerging conflicts based on financial systems and the ethical and practical concerns of case managers. BH knows what he was able to do before network restrictions and how the collaboration is affected by increasing restrictions brought by the lack of knowledge of care providers who are not empowered to create meaningful and appropriate solutions outside protocols that are based on cost reduction and computer-required documentation
These observations are meaningful after 30 years in advanced practice of case management.
BH perceives that practical conflicts and ethical conundrums have impacted the scope of practice for bedside RN-CCMs; for BH, changes have minimized the autonomy and professional preview of case management. BH’s combined attributes of critical thinking, empathy, and knowing when and how to challenge systems provide meaning to him. Alternatively, the next interview reveals similar insights and different ways of confronting increasing restrictions.
Colin Marble (CM): Advocating for better care one act at a time. CM agreed to be interviewed when contacted at the recommendation of a previous co-worker. CM and I worked for several years in the same department, and briefly on the same team, performing various duties related to compliance and insurance authorizations. She requested we meet at her home on a Saturday morning because she would be more focused and because she takes care of her mother, who has dementia and has moved into 97
CM and her husband’s home. She lives in a suburban neighborhood with meandering streets and very little outdoor activity on the clear sunny morning that I visited. When I arrived at her home CM was wearing a plain skirt, top, and basic walking shoes, similar to her work attire. She let me into her moderate-sized, immaculate home that was built in the 1950s, based on the general layout. Her home appeared to be very organized and without clutter. She ushered me into the kitchen, which appeared have been recently remodeled, showed me the coffeepot, and offered me bagels in a bag she had bought and went to check on her mother. I did not meet her mother. The part of the house I was in— the living room, dining area and kitchen—had a large window looking out to the street, and a dining room alcove with another large window. The views were of adjoining yards.
The house contained paintings of outdoors and family pictures scattered on table tops.
When she returned we settled on the kitchen table for the interview location.
During the interview CM postured with full attention to the questions, made direct eye contact, and appeared eager to offer responses about her professional experiences.
CM is in her 60s, approximately 5’5” tall, attractive, wears simple (if any) make-up, energetic, and moves quickly and thoughtfully. Her original nursing degree was, like mine, earned from a diploma program in 1971. After 25 years she went back to school for her bachelor’s in 1997 and obtained a master’s in education in 2007, which she said was
“the hardest thing I ever did” (CM, personal communication, December 3, 2016). CM went for the master’s because she was turned down for a job for which she felt qualified based on experience but did not have the higher degree. She passed the first Certification in Case Management Exam offered in 1990s and has worked in workers’ compensation; 98 as a non-acute screener liaison in New England for nursing homes and rehabilitation centers; worked in management, marketing, and insurance; and performed home evaluations for insurance companies. She is now, like BH, a case manager float, although employed by a different tertiary hospital. Her passion has been professional interests, perhaps self-care related, addressing public policy. She participated in development of the Affordable Care Act by traveling to Washington a few times. In a somber note, she reports letting go of her commitment to these public forums because of the time commitment required to be at home supervising her mother, who has progressive dementia. The change reflects prioritizing personally meaningful activity in her off-duty time and the compelling value of family.
CM’s work schedule is 8-4:30 follows a pattern as follows:
The managers give us the assignments, unfortunately not in a timely manner. As a
float for me the hardest thing is I am usually picking up 20-25 new people every
day…and as of late we are not getting our assignment until sometimes nine
o’clock in the morning. So, I’m already behind the 8 ball when I start trying to get
my job done within that time frame, which makes it very hard.
I have to wait until they find out who needs to have coverage if someone’s
called out sick. And so, I’m usually one of the last ones to find out where I’m
going. I’m not assigned to a specific floor. So, it’s a little bit different where they
can just start right in on their job (CM, personal communication, December 3,
2016). 99
CM’s description of the first two hours of work every day includes initial delays outside her control on starting her day, finding assignment variables she cannot verify easily, and expectations of entering accurate acuity data for 15 to 20 patients into a computer system. CM implies her tasks are incorrectly or indifferently presumed by others as being easy to accomplish by 10 a.m. despite routine delays in knowing her assignment. The deadline administration imposes on case managers is a contractual obligation to insurance companies so an appropriate payment can be approved or denied and appealed before the end of that business day. All these activities are the result of managed care business processes in health care beginning in the late 1990s. These routine tasks-relationship events require clinical expertise more global than beside nurse scope of practice and have minimal significance to staff physicians. CM, like BH, knows health care changes are placing her role under the scrutiny of business ethics to meet contract agreements and are becoming less about patient advocacy.
CM next offers the following perception of her role and its value despite obstacles mentioned above:
My first goal of every day is to be the face of case management because I think
it’s a very worthwhile profession, otherwise I don’t think I would have been in
this [as] many years….I always try to make at least one person smile every day.
That is how I start. And then I go to whatever floor I am assigned to and try to do
the very best job I can. I try to prioritize, obviously, based on the number of
patients that I have. Who’s going first, gets the first eyeballs from me (laughing). 100
I try to do as much as I possibly can to help my patient because that is why we are
there…
For every type of patient that comes in [we do risk assessments].…Now
that’s part of our computer program....Almost everybody is a high risk. It’s rare
that we don’t have someone who isn’t high risk. So yes, risk assessments are the
first thing I do. So, I go through my patient list. I try to read through before I start
my job if it’s possible to read through every single patient’s record, because as a
float I have no idea what’s going on and I’m only as good as the person in front of
me left. Not everybody always leaves an update so I know what to do. I have to
figure it out. I’m sort of a detective sometimes, you know. So, I’ll go through all
of my patient list to try to determine who needs my first priority. The other part of
the assessment is we have to do the Interqual. Sometimes there isn’t good
documentation in the record. So, you have to go up and see the patient and really,
you spend more time trying to assess it yourself so it makes it a difficult thing to
try to accomplish by 10 o’clock and make sure everybody’s at the right level of
care. So that’s the biggest part of my morning, just trying to get organized, getting
the Interqual done, the utilization piece and getting ready to meet with the staff at
team meetings we have, they call them a huddle (CM, personal communication,
December 3, 2016).
This comment further details CM’s task-relationship processes and how she prioritizes her time. Her implicit values reflect autonomy and justice determining priorities. For example, CM values accurate documentation. If documentation is 101 inaccurate or insufficient, then the hospital’s reimbursement can be jeopardized.
Ultimately CM’s measured time to address other concerns is reduced. CM continues to describe how a lack of knowledge of patient details affects managing outcomes of her efforts.
Not everything is always accurate [in the chart]; unfortunately, I do find that
reading rather than actually talking to the patient. So that is one thing I find very
important for case managers to do, to be at the bedside, to verify themselves what
their address is, where they are going on discharge. Some people don’t even do
that. That is a big deal. Especially as a float and I go up there and they say,
“Everything is ready for discharge” and I go in there and say “OK, you are going
to this address.” And they say, “Oh no, I’m going to my daughter’s.” Do you
know what I mean? So, people haven’t followed through on all the things we need
to do to coordinate that whole plan of care. And it’s sad (CM, personal
communication, December 3, 2016).
CM values advocacy to ensure adequate care of patients. Lack of trustworthy documentation impacts her ability to advocate effectively. Effective advocacy includes relying on others to provide timely and trustworthy information; if this connection is jeopardized for any reason, CM feels compelled to fix the error in documentation so the inaccuracy is not compounded. This is another impact of managed care and dependence on computers as the medium of collaboration to promote fast-paced task work. Doing no harm requires diligence in communicating through electronic mediums. 102
In the next scenario CM describes obstacles to advocacy due to a physician’s directive. In this narrative, the social norms support a nonnegotiable discharge plan even though the details are not perceived to support beneficent ethics of compassionate care:
There is one doctor who will not let his patients go to rehab. They go home, even
if they need rehab, he refuses to sign off on that. Which I’ve given up trying with
that particular physician, honestly, because it’s like hitting your head against the
wall. He doesn’t want to hear it, he doesn’t support it and that’s his way. And his
patients know before they come in, according to him. So, they know they are
coming in for one or two days and going home.…Whether I think it’s a good idea
or not. And he won’t allow home supports. I don’t know [of any consequences]
because as a float I can’t tell you but I know that has occurred. So, someone who
is taking care of people like that would probably be able to answer that far better
than I....But there might be a time where it’s a little old woman, I might
[think]…“Gee, I’d like to help her get one more day,” but you know, sometimes
you can’t. We discharge all times of day. So sometimes, even just staying until 7
o’clock at night might be OK, making sure they have their dinner before they go
home, that sort of thing (CM, personal communication, December 3, 2016).
In the excerpt above, CM perceives success and failure in collaborating efforts.
Empathic maturity and emotional intelligence assist CM in navigating challenging scenarios. CM perceives a lack of collaboration in the physician’s rigorous limitations on post-acute care and after an attempt to discuss, she backs off. In this scenario CM perceives that asserting patient advocacy is futile because the social context has allowed 103 the physician to designate all dispositions regardless of patients’ needs. For the aging frail female, CM is realistic in negotiating a few hours versus a full overnight delay of discharge to include one more full meal. Her critical thinking and experience contribute an awareness of the potential for clinically inferior care or harmful consequences to vulnerable patients....The motivation directing rigid disposition plans or timing are often financial and more complex than this paper’s scope. If an RN-CCM has experienced more flexibility in her early career days before managed care and contracted networks, this physician’s approach appears almost draconian. To newer RN-CCM participants, this rigidity is expected, not obstructive, and understood to be related to fiscal solvency for the network. The ethical implications of these kinds of problem-solving situations vary based on how the case manager perceives the value and meaning of the case manager’s influences in care-planning decisions.
To offset the lack of influence, CM expresses a pride in her public image as an
RN-CCM. Unsolicited, CM recalls how a patient’s family member was relieved when she recognized CM as speaker in a past conference.
You just never know who is watching and who is paying attention and who is
doing all those [recommendations from practice experts]. That is why I think we
have such as important role because we pull everything together to make it
smooth for our patients (CM, personal communication, December 3, 2016).
Despite a myriad of tasks and obstacles, CM experiences self-confidence through her personal efforts in professional education events guiding others toward moral actions. 104
For CM, problem-solving requires knowledge about clinical issues and, as with the next participant HR, empathic maturity in choosing moral actions.
Helen Roberts (HR): Being compassionate for other’s imperfections. HR perceives advocacy as accepting patients where they are and not where the system or the medical staff want the patient to be. HR agreed to be interviewed when approached by the intermediary for this project. Although HR knew who I was from a previous interaction referring her CV as a potential hire, I did not remember her. We met outside her office in a hospital corridor adjacent to her medical practice location. HR set a quick pace through the clinic corridors to a door into a cramped, windowless, soundproof room of four cubicles, two of which seemed to be hers, although separate computers and printers were in each space. We met after five p.m.; the office was empty. About 5’4” with short brown hair and a pleasant smile, HR was dressed in a business casual skirt and top with a lab coat over the back of her chair. Her eye contact was frequent although brief, as she looked at objects nearby or the computer and bulletin board when searching for words. The phone was close to her right hand and, based on our conversation, it was her connection to the outside world—including her patients.
In her mid 50s, HR is a married woman who graduated with a BSN in 1983. She is fluent in three languages: English, Portuguese, and Spanish. HR started case management work in 1992, just before both DRGs and outpatient coding (APC) were becoming the standards by which managed care companies set reimbursement rates and the creation of networks of providers. HR began as a workers’ compensation case manager, the first professional case manager nursing role in the health-care system. Like 105
BH she was one of the first applicants for the case management certification exam. HR describes herself as a generalist and refers to many years employed as workers’ compensation case manager, telephonic case manager, long-term-care case manager,
“you name it I’ve done everything” (HR, personal communication, December 1, 2016).
HR’s relatively early certification and her independent role in workers’ compensation oversight occurred before managed-care protocols took benefits management out of the hands of front-line case managers. Her long tenure in this role may influence her perseverance with highly complex patients and patient-centered care planning. She perceives advocating for high-risk populations as a professional duty and honor.
At the time of this interview, HR was employed on a multidisciplinary team of nurse, social worker, physician, and other paraprofessionals within a tertiary hospital ambulatory primary care outpatient setting. HR describes her environment and daily interaction:
I help with transition of care and I’m here to help the patient and primary care
practice get the right care at the right place and at the right time. We work with
Medicare and Medicaid, and state health commercial lines. [ I am part of the]
Accountable Care Organization (ACO)....I work with all the interns, residents, but
if I have an issue with something I bounce it off my colleagues. (paraphrasing) I
bounce things off the nurse case manager who trained me here and the social
worker assigned to the practice. Objectivity is important when you are struggling
with a case (HR, personal communication, December 1, 2016). 106
HR works in an organization that is structured to be accountable for quality measures. Therefore, collaboration with her close-knit team members yields positive results for her and the patients when unexpected admissions are reduced and utilization of services is low. She continues to give details, describing her workday starting at 7:30. As other participants experience in the acute settings, HR often covers for others who are off duty and who work in community health practices under the hospital umbrella.
Our days are following patients who have come out of the emergency room,
making sure they transition safely to home. [Also, for] patients coming out of an
inpatient admission, making sure they have a primary care follow-up visit, they
have their medications from the pharmacy we do a med reconciliation.…When
patients go from here [clinic visit] or the emergency room to a nursing home or a
rehab we call and do a “warm handoff.” I can’t tell you all the things I’ve
prevented by calling and saying who I am, I work with the primary care physician
(PCP) and I give them the post-hospital follow-up things that need to be done on
the discharge instructions and many times its saved quite a…it’s saved patients
from coming back (HR, personal communication, December 1, 2016).
HR’s day includes tracking emergency room visits of patients registered with her physician practice. HR is involved with patients directly, often face-to-face or by phone, and follows them over time, not only by episodes in the acute setting. In response to the question of positives and negatives HR comments on the experience of stress and stress relief due to inability to meet patient demands: 107
It’s very stressful.…You know the patients are very demanding, they are very
needy.…They can do more than they admit. The problem is they are just so
overwhelmed and complicated. They have the depression, the psychosocial
system going on, they have limited support systems, they can’t get here to their
appointments, they struggle.... So many things you know, you need to multitask,
you need to be able to know when to step away sometimes (HR personal
communication, December 1, 2016).
HR perceives advocacy as meaningful. When patients are demanding, she experiences a response she labels stress. She sees this stress as the result of demanding patients. Demanding patients are needy because she believes they are fearful or insecure.
She perceives physically stepping away as a self-care response to mitigate this stressful experience. The narrative above reveals ethics of beneficence and non-maleficence as well as emotional intelligence defined as assessing and responding to the needs of others while also regulating potentially negative internal responses by physically stepping away or limiting access by phone.
HR continues her detailed narratives on about stressful encounters. She offered compelling stories describing meaningful, multifaceted advocacy activities for her client population from basic tasks to complex problem-solving.
There is so much going on with durable medical equipment we have to do to
provide them. To get the patient a wheelchair or to get them transportation, it isn’t
easy anymore. It’s very time consuming. There are paperwork documents, you
have to track down the PCP, they are not always here…Patients are very easily 108 confused, they have to trust us. I have a great rapport, they just call me and tell me what they need and I immediately work on [it]. I just had a daughter I had to call that left some FMLA [Family Medical Leave Act] forms that she needed completed because she is the caregiver for her dad who is elderly. You know, I just immediately scanned it and got the doctor who completed it and now she wants it faxed backed to her.
I had a patient call me 17 times on Monday. I had just returned from two weeks of being gone on vacation. She has major behavior health issues and she was manic! And she is also very complex medically, but I had to call her back. I spoke to her once or twice but then when she kept calling and calling I just had to let it go to voice mail. I didn’t need to return that call to her because she was just trying to suck me into her drama and what it was she basically wanted me to schedule her a dental appointment for a tooth abscess that she’s had for weeks.
She is a diabetic, she knows it needs to be taken care of. She has [XYZ] insurance. I clearly told her the dental resources. My job is not to pick up the phone for her and make her an appointment. She is fully capable. She is educated, a self-advocate for years for mental illness, but she wants someone to do it for her. I said, “This is not my role, this is dental insurance, call your case manager at
[XYZ], but in the meantime, you can to [XX] medical center to their dental walk- in clinic, you can go to [ZZ], you can go to [YY],” I even gave her [ABC] Health
Center [part of hospital system that has a unique dental division for immediate care]. She was being a little bit off but I had to know how to handle her, not let 109
her stress me out, which she has done for four years (HR, personal conversation,
December 1, 2016).
In these stories HR questions basic ethical issues of autonomy and benevolence about who decides the best options when choices are possible. Choices are not always possible in today’s restrictive networks benefit allocations. Another implicit ethical topic presented is the question of whom the case manager should endorse when problem- solving patient needs, medical staff or frail patients? “So, some of these patients, the doctor has their idea, everyone has their plan but what does the patient want” (HR personal conversation December 1, 2016). HR’s advocacy role includes navigating through conflicting opinions on resource allocation, a concept informed by distributive justice. RN-CCMs’ problem-solving requires emotional intelligence and clinical expertise uniquely suited for the duties of RN-CCMs.
Maria Jay (MJ): Using infinite patience resolving infinite problems. MJ works in an acute-care hospital setting within a large network that is a fast-paced, resource-intensive context. MJ was recruited for an interview by a mutual acquaintance. I knew MJ professionally many years ago. The date and time for the interview was pre- arranged by the intermediary. We met in an ice cream/coffee store across the street from her employer. The setting was semiprivate; ambient music was unavoidable. The 5 p.m. time was less active in the store; outside was dark. MJ gave me a spontaneous smile and hug when she approached my table. The table we used was in a corner; MJ’s back was to the open windows and store clients to increase a sense of confidentiality and decrease the likelihood that random clients or people leaving work might recognize her. 110
MJ is a mid-40s attractive woman of color whose smile and presence make a welcoming appearance. Of note, the influence of race and gender may influence how MJ navigates conflicts described below. The potential risks of gender and race in health-care contexts are based on social bias and unlikely to be introduced as an overt impact on health-care conversations among professionals who are problem-solving as a team. Race is mentioned here as a unique variable among those interviewed, much as gender with
BH.
Arriving for the planned interview, MJ walked gracefully and with confidence, a consistent public persona from my experience working with her in the past. She wore professional, casual flat dress shoes, uses moderate make-up, and has a simple bob hairstyle. Her tone of voice is steady with gentle fluctuations and occasional chuckles reflecting irony or challenging situations. MJ has been a nurse for about 25 years. She passed the certification in case management in 1998. At that time health care in
Massachusetts was converting to a kind of universal coverage. Capitated contracts were in vogue and involved complicated contracts between insurance and health-care networks. Incidentally, capitated plans in Massachusetts survived only a couple of years because acute-care hospitals lost significant capital by caring for the networks’ sickest members. MJ has accrued approximately 20 years of case management experience. In
2014, she achieved her master’s in nursing. Her background is cardiac surgery, workers’ compensation, and home care. MJ performs case management in acute inpatient episodic care, as do BH and CM. 111
MJ began the interview describing her current team position (not float) covering acute patients admitted to the women’s cancer program and general surgery. She performs high-risk assessments and utilization reviews using software called Interqual, introduced by an insurance company the early 2000s to consistently qualify (or deny) reimbursable care based exclusively on clinical information for the treated condition and not social or complex medical circumstances. As CM indicated, patient care must qualify each day for the hospital to be reimbursed. DRGs are no longer the standard for reimbursement. MJ shares an office with five desks of which three are for case managers, one for a resource specialist, and one for a social worker. “Other people come in and out of the office if they need something because we are in [the center of the hospital building]” (MJ, personal communication, December 1, 2016). The office is on the 10th floor; her patients are on the 15th and 12th floors.
MJ’s day begins at 8:30 a.m. by running a census report for her permanent clinical assignment.
Lately we’ve been covering other areas, other than what we normally cover.…We
have to look at what [the management team] assigned us (laughing) for the day.
We look to see who may be discharged…who needs to be Interqual-ed because
they have Medicare, if there are any follow up calls we need to make from the day
before and make those first thing.…Then we go up to the floors and meet with the
teams to see what’s happening with the patients.…Basically, if there are not
enough people to cover all the areas then we kinda get assigned; I may get
assigned four patients on another floor that I normally wouldn’t cover and 112
sometimes somebody else may get assigned a number of patients depending on
the census. It strictly goes by how many patients you have, not so much how
difficult those patients are that you may have. We really don’t know what the
magic number of “OK, you have enough here so we’re not going to pick on you
to give you more patients.” (laughing) It’s elusive…A normal assignment would
be like 15 patients…and it can go all the way up to 26 patients in one day. That’s
a lot (MJ, personal communication, December 1, 2016).
In this humor-laced comment, MJ reveals a mercurial structure for assignments.
Changing assignments are a conflict in performing employer expectations and too many patients creates a burden.
Alternatively, MJ positively identifies her role in direct patient care:
Even though I’m not doing the hands on…I’m still directing and speaking with
patients, their families, a very intricate part of whether they are going to be able to
leave the hospital or not…where they are going. So, I really like having those
details (MJ, personal communication, December 1, 2016).
She identifies feeling split on assignments between patients in different geographic locations. “You cannot be in two places at once” (MJ, personal communication, December 1, 2016). By these comments, MJ sees patient interactions as meaningful experiences of advocacy and therefore they nourish her self-worth.
MJ continues to describe daily relational task duties:
To deal with the multidisciplinary team that even though we are all there for the
purpose of managing and taking care of that patient, everyone is not always on the 113
same page as to what’s going to happen. So, I think the case manager has a tough
job because you are advocating for the patient, not just for one stakeholder but a
bunch of them, all the…and everybody (sigh) has a different agenda, so you have
to try and connect them all and help everybody to see exactly what the patient
wants or what the patient is looking for (MJ, personal communication, December
1, 2016).
MJ recognizes the various priorities influencing care planning decisions in the following statement:
It’s frustrating sometimes, it can be very frustrating especially when you are not
treated nicely, when you are trying to advocate for the patient or when you say,
“The patient needs something,” “The patient told you”…and that’s another thing,
a lot of our practitioners or providers don’t bother to ask the patient what is it that
they wanted. They just come up there, everyone is working on the plan and they
are coming up with the plan and then they decide, oh this patient needs to go to
rehab because this patient is…but no one asked the patient, “What do you want?”
and the patients says “I’m not going to rehab, I don’t believe in it, I don’t think
it’s good, my husband is going to take care of me.” So, then we have to go back
and say “You know you didn’t ask the patient and this is what the patient wants.”
So that gets a little tangle, especially if the team is kind of headstrong and doesn’t,
they don’t agree with what you are saying but what you are saying is what the
patient is saying. And ultimately they can’t force the patient to do what they, what
that person doesn’t want to do. That’s like a huge thing, ’’cause then, did anyone 114
ask the patient? ’’Cause we are out here arguing or discussing it, but what do they
want? (laughing) (MJ, personal communication, December 1, 2016).
This interaction reflects MJ’s ability to navigate care planning among physicians with one view of what is best and the patient with another. By educating and communicating, MJ brings a care plan into focus on the patient’s right to autonomy—i.e., making choices on care planning based on personal values. In this case, no one has a wrong view, just different views of what is best.
The daily duties of case managers contain these kinds of collaboration.
MJ’s comments below illustrate dissonant motivations emerging between her view of interventions and a conversation regarding a difficult (behavioral or high- utilization) patient’s transfer out of the acute setting.
When we screen someone for rehab facilities and their response.…they won’t say
it’s a difficult patient, they will say, “Oh we don’t have an appropriate bed
available.” We all know that means more than just the fact that they don’t have a
bed (chuckling)….The years of doing the job, and sometimes you know
exactly…this is going to be a difficult placement and when you have ten screens
in and of the ten, eight say the same thing, something is amiss.…sometimes the
insurance will not be 100% and it won’t pay them what they are looking for to get
paid or the person has behavior issues or they may not have a good solid plan of
what’s going to happen after rehab, where they are going to go, and all of those
things are things that facilities are not supposed to say “no” for but they
do….Sometimes, if it doesn’t seem like a patient is too bad or a problem I’ll call 115
them on it.…And some will tell me and some will say, “Oh no, we just don’t have
an appropriate bed” (chuckling) (MJ, personal communication, December 1,
2016).
In this description, the scope of tasks reveals daily communications that include hidden language camouflaging conflicts between her role as advocate and the financial priorities of nonacute screeners. Ethical principles of distributive justice and actions absent of trustworthiness compromise ethical actions such as trustworthiness. As with
HR, MJ uses emotional intelligence in discerning when to challenge the authenticity of conversations containing hidden language.
In the statement above MJ describes a tough job that requires emotional intelligence to navigate through organizational obstacles. Alternatively, MJ identified two personally valued events highlighting her meaning of advocacy.
When the patient and their family are very nice, they are just personable they get
along with everyone, they are like compliant, they want to do what you are telling
them to do and they just want to go. You want to help them because they are
trying to help themselves and they are very pleasant, they are not making
demands or having expectations that are not realistic and the whole unit kind of
gravitates toward people that are like that so you want to help them. Or you see
someone who is just a sad case, who doesn’t have support persons, they don’t
have any family, they are poor. You, I tend to help these people figure out what it
is we need to do to get them where they need to be (MJ, personal communication,
December 1, 2016). 116
MJ’s descriptions reveal the wisdom of experience in advocating for patients in acute-care hospitals. The examples above and other situations involving contentious life- and-death treatment decisions create a different context from MC’s telephone encounters and JG’s protocol enhancements. MJ’s stories demonstrate experiences of how organizational hierarchy and communications can create roadblocks leading to conflicts, creating consequences affecting patients, families, and front-line staff.
Kelly Freer (KF): Knowing why and how to fix a problem. KF agreed to be interviewed through the same intermediary as HR. KF met me on the 10th floor of the hospital about 7 p.m. Heavyset with moderate makeup, she was dressed in simple casual work clothes with a white lab coat, and had a pleasant professional demeanor. She escorted me into a small office with two computer screens and a large printer. The room had no windows and was big enough for two chairs to face each other. KF is a float nurse with no consistent team affiliations, so the office in which we met is not hers; it belongs to those permanently assigned to specific units. As a personal disclosure here, I worked with KF years ago so she knew who I was, although we had not spoken in about four years. KF mostly offered direct eye contact during the interview. She paused before answering questions and kept a moderate tone throughout.
KF, now in her early 50s, graduated from a diploma program in 1986, received a bachelor’s in nursing in 2015, and her certification in case management (CCM) in 2010.
She began her case management career in 1990 as a medical surgical nurse and on telemetry units. KF participated in the early days of quality auditing by Medicare. Prior to that time, Medicare had rarely audited claims. Private insurance managed care auditing 117 policies included scrutinizing utilization to reveal potential cost savings through denial of payment. KF worked at the state government auditing offices called State Peer Review
Group (MassPro). At that time, she learned about case management certification and pursued a recommendation to pursue case management as a professional career move.
From that job she came to her current employer and has worked in her current role a float nurse case manager for 15 years. Her position is much like those of BH and CM but during off hours.
My role is a little bit different as I work Thursday, Friday, Saturday, Sunday. So,
the delivery is a little bit different. I’m here two days and then during the weekend
the model is a little bit different. So, on Thursday and Friday I come in and I am
assigned to cover somebody whether it’s an absence, a sick call, planned day off,
leave of absence. I can go anywhere throughout this organization. I’ve been to
every service, every building, everywhere. I get a little bit larger assignment
because I am here ten hours. A lot of times I’ll take in an assignment and like I’m
called upon: “Oh can you do this?” or, “Someone had to leave could you pick
up?” “Can you follow up after hours?” Stuff like that. And then there is your
typical utilization reviews in the morning, like the Interqual. And you know, we
run our rosters, assign ourselves to patients, we attend huddle reports, we start the
work for the day and stuff. And then I do a sign out for all these patients every
day. And then, it’s often times she tries to keep me in the same place for two days
but often that does not necessarily work out. So, then I just start somewhere else
the next day...and then on the weekend there’s eight people covering the three 118
buildings. In that method we cover by floors so that the process is a little bit
different. So, the goal is to follow up on planned discharges but certainly it’s
turning into a bulk of all the patients that came in at the end of the week of their
plans that haven’t been finalized so we are doing all of those discharges. Plus, we
do the Interqual on the weekends also (KF, personal communication, December 1,
2016).
KF’s choice of a consistent weekend work schedule implies value and meaning in autonomy, observations of different systems, and her capacity to add to clinical knowledge. She applies emotional intelligence to advocate among various personalities and clinical priorities. Permanent team assignment is not as professionally meaningful.
KF continues to describe the meaningful elements of her employment:
Academic environment, the complexity of patients, basically no day is the same. I
like floating because I have an interaction with so many people here and it really
has changed my way of thinking…where I’m global and thinking big picture
rather than just being focused just on one type of patient. Like a cardiology
patient and that’s all I’m seeing. I know a lot about a lot of things but not so much
an expert in one particular area… I’ve become a really good problem solver…and
I work extremely independently. So, these are all advantages to my role…but that
scares a lot of people from floating. They like to come in and have a very…I just
go with the flow (KF, personal communication, December 1, 2016).
KF’s perceptions have changed because she values the challenge of the transient float RN-CCM advocacy role. For example, KB identifies conflicts in problem-solving: 119
[Things] really gets stalled sometimes, like in terms of increasing process or like
standardized…like I’m a really big on formatted charting and things like that.
Like streamlined processes. Like that gets a little off the rails…I think it
something because people, it’s such a large department and we don’t have an
educator per se and then try to get people to do what you need them to do can be
somewhat challenging. I think just in the last year or so just in the last year the
volume has really increased and I think it’s just hard for people to just keep the
people’s head above water now.
MM: So, when you say volume has increased you mean the work load or
the number of patients?
KF: People have been picking up…most of the assignments are on the
medicine team, typically you can have one pod which can be 15 people,
depending. On Oncology they cover two full pods which can be very challenging
(KF, personal communication, December 1, 2016).
A float’s job comes with daily changes in clinical assignment; caseloads vary. For an independent float, knowing and acting on safe protocols can be confusing and cause conflicts among staff. KF suggests educator mentoring would mitigate conflicts emerging from inadequate, incorrect information being provided when problem-solving and advocating.
A lot of times, I mean obviously the Medicine teams are focused on the medical
aspects of the care. And then we, or I go in to talk to a patient and you are like,
“OK that’s not going to work in this household.” And then we go back to the team 120
and I say, “You know, I met with this person and the family. They’ve exhausted
these types of options and they are feeling like they are going more toward a plan
in this direction.” So, a lot of times, and it all depends on if it’s a case manager
that can or wants to spend that time looking at the big picture as to what would
best work.
MM: So again, it’s the case manager’s value system—
KF: And a lot of it I think it’s their own assessment skills and just based
on their experience of what works and what doesn’t work.…and then in terms of
insurance we kind of know what will cover what. If they are going home with IV
antibiotics and they are Medicare, Medicare doesn’t cover that so now you are
talking rehab, and placement unless they want to pay out of pocket.
MM: So, hearing what the patient prefers but knowing that won’t
necessarily be the way you can work it out might create some kind of dilemma.
KF: Right (KF, personal communication, December 1, 2016).
KF reflects above on her collaborative role problem-solving between medical staff and the patient knowing or unlikely or available options. Mitigating causes of conflict involving available options, medical team motivations, and patient choices requires a competent case manager. KF identifies herself as the collaborative advocate in these situations. Toward the end of the interview KF admitted her role and interactions with patients affect her personally:
It is very saturating, extremely saturating. I tend to take a lot home with me…it’s
hard, I often think about a lot of patients all the time. I think, “Aw geez, I wonder 121
how that person made out,” or wonder how that family is doing. All that kind of
stuff. It’s hard. Like if I go back to a team and I ask, “So whatever happened to
so-and-so?” They say, “Oh they passed away,” or “They are doing good,” stuff
like that…having somebody with one parent that has passed away and then an
older mother and you see this. My sister had a renal transplant a couple of years
ago and stuff like that. It’s hard. I think we all can relate in some way. We are all
not 22 anymore. And and it, it… just proves to you that life can change at any
time and it could affect anyone of us. I deliver care in terms of, “If that was me or
a family member in that room, how would I want to be spoken to?” and, you
know, options, and how do I explain things to people? (KF, personal
communication, December 1, 2016).
KF offered a window into her world of floating assignments that, while mentally stimulating and challenging, also implicitly isolates her and limits continuity with patients and staff with whom she intervenes. This reflection indicates an empathic maturity and potential for moral distress if the sense of disconnection becomes overwhelming.
In contrast to the acute care float nurses’ experiences described by BH, CM, and
KF, the next participant performs administrative responsibilities for population health protocols of outpatient settings similar to HR.
Proactive Nurse (PN): Mentoring others to lead toward healthy possibilities.
PN was asked to participate by a professional associate. She was interviewed in CM’s house, which is about 15 minutes in another suburb from her own home. PN arrived 122 slightly late and was very apologetic because she was lost in the meandering subdivision.
She was dressed in business attire of pants, dress blouse, and walking shoes. PN is in her
60s with a professional appearance and imbued with vitality. She appears about 5’6” and average weight. She wore almost no jewelry and a wedding ring and band, simple makeup and a carefully prepared hairstyle gave the impression of someone ready to engage in a professional discussion. Her tone of voice was firm and gently modulated, not pressured, angry, or tense.
Her eye contact was direct throughout the interview. She used her hands when discussing her newly assigned role and seemed to consciously stop using them, giving the impression that she is familiar with public speaking or giving meeting presentations.
During the interview, she sometimes repeated information offered in previous answers, suggesting that she viewed interview questions as redundant. When a term was not clear to me, I would ask for clarification, which seemed to put her at ease in knowing the intensity of the interview was not focused on what she knew about health-care systems or not judging her administrative tasks in the system, but rather her perceptions of working as a certified case manager.
Her background includes a nursing diploma from a local nursing school affiliated with a community hospital in the area, and a bachelor’s in business. PN passed the case management certification in 2004. Case management at this point was becoming more oversight of high-risk patients: preventing catastrophic events by monitoring non-urgent metrics determined by the insurance industry. She received an MBA in 2009. She is a recent president of the Case Management Society of New England, which is a peer- 123 elected position the local chapter of CSMA. Her clinical experience includes medical surgical units, emergency department, nursing management, and, for the last twenty years, in case management. Her specialty is self-identified as administrative leadership.
PN currently works in a large integrated hospital health-care system called an
“MCO, a management service organization, providing oversight of clinical activity for high-risk population management within a large suburban integrated health-care system.”
She reports to the chief medical officer and has recently hired two case managers to work under her, assigned to clinical practices within the hospital network. Her title is “director of network care management,” the scope of which she describes below:
[The job is] clinical and performance oversight of again, ACO Medicare
population, the high-risk population as well as the value risk-based plan, the
commercial population. We do follow [some commercial products] … within the
accountable care organizational units that are part of a large system to
standardized the policies and procedures to address quality and efficient
population health management. We are an accountable care organization holding
a contract with Medicare to provide quality and efficient care to the Medicare
population.…It’s not a Medicaid ACO contract at this time.…It’s not strictly
targeted to the Medicaid population. We have dual eligible individuals that carry
both Medicaid coverage as well as, you know, they are dual eligible for Medicare
and Medicaid within our accountable care organization population.…So right
now, at this point in time, right now I work directly with the care management
leadership and three affiliated units that are part of our integrated health-care 124
system to address a number of components. One is staffing policy and procedures,
training, education, standardized care that includes evidence-based practice.
These are not three separate medical practices. We call them units in the
sense that we have one unit, one hospital system that affiliated itself with the
ACME health system. Another unit, such as the Primo, [and] the Segundo health
system, we call it a unit, like the Unity Hospital, and then we have the Trios unit,
so there are three units (PN, personal conversation, December 3, 2016).
PN articulates in simplest terms the current administrative structure. She places significance on emphasizing that her role is new and transitional. She agreed to assume her current position because the network needed an RN-CCM to oversee hospital-funded case managers assigned to high-risk populations. Her role is to educate, train, and prepare the nurses for certification exam and to prevent quality lapses and duplication of services including readmissions. Readmissions are costly events for hospitals because Medicare has stopped reimbursing for any readmissions with sixty days of an acute hospital discharge for complications such as a post-surgical wound infection.
PN’s day is the least structured of the nurses interviewed. She refers to “lots of meetings” with case managers and management leadership:
MM: So when you are doing the job no one covers for you when you are out.
PN: Right. And I do want to say too, that right now, it’s not going to be a
long-term plan. I am actually also working to build, we are just ramping up to
start this the first of the year, overseeing a self-insured population program that I
was asked to develop with my boss. So, we have just hired two full-time case 125
managers. It’s the first time ever…[that] a commercial younger population…is
prevalent, that is working, providing traditional care, providing disease-
management-specific program enrollment support.
MM: What kind of disease management programs?
PN: We are going to start out with. (pause) We are, you know, obviously
going to provide transitional care. And…we are starting out to focus on diabetes,
chronic lung disease, and heart failure and then we are also looking at, you know,
seeing how we do with that and reassessing and expanding it further....As far as
nurse case management is concerned, I am going to be working, training, and
mentoring the population health network care managers that I work with, the self-
insured population as a temporary basis, right now, I’ve been asked to supervise
and work with two full-time bundled nurse care managers who had been managed
by a physical therapist but we really wanted to standardize in their job description.
When they were hired, they needed to be supervised by someone in case
management. So, it really presented as a dilemma and my boss decided I would
step into that role temporarily and help them temporarily (PN, personal
conversation, December 3, 2016).
PN’s job is a change in responsibilities for her and consequently changes the work environment for those who report to her. She takes ownership of the responsibilities being requested and perceives this experience to be a temporary and yet significant contribution to patients’ well-being. The focus is on network monitoring patient compliance and providing care to those patients to meet metrics for reimbursement. RN- 126
CCM duties in this context are to help patients conform to protocols of care defined by insurance and national guidelines of disease monitoring. Therefore, case management duties are more prescriptive than in intense hospital episodic duties. Nevertheless, the motivation to navigate the patient through the rigors of quality measures requires skills in problem-solving, but over an extended time. The circumstances creating this role for case managers is clarified next.
PN refers to her oversight of the hired “bundled nurses” facilitating a new project sponsored by Medicare (CMS).
[It’s a] new value-based contract with CMS that its growing across the country
and it will likely continue to grow. But depending on the type of contract, it’s
when for a specific bundled care, it’s similar to a capitated program [one payout
for all services related to one episode of care, i.e. hip surgery]. And so, total joint
replacement population that has been identified that enters the hospital system for
that type of surgery would be followed contractually for 90 days. So, the two care
managers that are assigned to follow a bundled patient population would really
supply support services for that patient for a 90-day period. And it starts when
they enter the hospital system. The expectation is to provide enhanced quality
case management services for 90 days and with the goal of reducing
complications and improving quality of care, improving access to care, education,
self-management, self-support, for the full 90 days (PN, personal conversation,
December 3, 2016). 127
PN’s example reveals how the influences of regulatory contracts drive the scope of practice for ambulatory case managers, similar to the work of HR and participants JG and MC below.
PN identifies two positive parts of her work as the standardizing of clinical protocol so that practices produce required metrics consistently across all three units.
Also, PN expresses pleasure in mentoring her new staff to become certified case managers.
At a network level [standardization] is good thing. I love within my new role to
do that very thing: To standardize policy and procedures for a minimum
expectation and to helping to mentor folks that don’t have that but certainly have
the experience and background to meet a job description with a plan to become
certified within 15 months of their being hired.…It’s a really challenging role
when you take a large integrated health-care system. So, we are responsible for
managing high-risk populations so we are talking 40,000 Medicare lives. And we
are talking close to 115,000 commercial-value-risk lives.…It’s a significant
number of lives so with the staffing model that we have right now we are
addressing just over 5% of that population across the board (PN, personal
conversation, December 3, 2016).
The volume of covered lives presents several challenges in managing time and choosing interventions that are both time and cost efficient. The program has been created based on the financial actuarial history showing that high-risk populations need consistent monitoring to prevent relapses or new complications. The RN-CCM is less of a 128 care planner and more of a patient monitor. Therefore, scopes of interventions are limited and broadens the number of covered lives per RN-CCM. In addition, potential conflicts are identified as challenges of interdisciplinary team collaboration on the bundled care structure.
The interdisciplinary team across the board [is] a licensed team-based model
predominately with registered nurse case managers with bachelor degree and the
goal is that the team is all certified in case management and we have licensed
social workers that are part of the team, and we have pharmacists that are part of
the team so it’s a multidisciplinary or interdisciplinary model in that sense….The
negatives are, because it’s a network-level position and you are responsible for a
far larger group of individuals and have to bring together leadership and directors
of care management and buy-in to achieve, we have to be successful in our
contracts. We do have to achieve all the quality measures and efficiency measures
that tie into the ACO Medicare shared savings contract. We have to achieve
success and achieve all the HEDIS quality and efficiency measures that are
affiliated with the value-based-risk plan. So, we really have to and at the same
time agree to embedding evidence-based care and agree on a standardized process
and procedures that exist across all those multiple units and working with multiple
providers in the community. So, it’s from hospital system, you know, bridging
that gap, working with providers in a patient-centered medical home way. Not all
our providers are certified as a patient-centered medical home practice (PN,
personal conversation, December 3, 2016). 129
PN explains above that expectations of quality care measures like Health Care
Effectiveness Data and Information Set (HEDIS) used by the National Committee for
Quality Assurance (NCQA) are also measures used in determining the success of the new bundling contracts. The essence of bundled care plans is to prevent avoidable exacerbations of chronic illnesses and complex conditions and to apply evidence-based interventions that are cost effective and do not take time-consuming or redundant or conflicting interventions by the physicians. The value of case managers described here is less about ethics of caring for individuals and more about monitoring large numbers of patients for consistent clinical quantitative details upon which performance measures and reimbursement are dependent.
To further describe the prescribed quality indicators that judge successful management, PN offered contract performance measures set up by agencies outside the hospital who negotiate contract reimbursement rates:
Performance is the target…they are process measures or outcomes measures.
Those are already embedded in the contract that have to be achieved. So we really
need to be successful in doing that. But my role, our role, our organization’s role
as a management service organization, we want to help our providers and our
health-care system to truly become a quality, integrated system so that we can
retain and increase our population base so we can remain sustainable and viable in
the future. It’s a very competitive health care landscape.
MM: Like no readmissions within sixty days, no infections. 130
PN: Right. There is, and this is not anything new, that HEDIS measures
have been in place for a very long time with all the health pans, the commercial
plans. And the diabetes population that you know, that they are achieving 95% of
the patients are being seen for their hemoglobin A1Cs. All the patients that
qualify have their annual, you know, based on the latest guidelines have
mammograms. You know, based on the latest evidence-based guidelines, Pap
smears, those that qualify by the population that qualifies…from a case
management standpoint is supporting achievement of those measures. It’s
educating patients and families on the need for better self-management of their
diabetes to prevent future complications….There are 33 measures, just for the
Medicare population. It’s quite a bit (PN, Personal communication, December 3,
2016).
PN described hiring nurses with a history and presence of being autonomous critical thinkers, advocates, and effective communicators at various levels of expertise.
Applying these skills is different in the outpatient setting.
Embedding …patients into medical home components with the nurse case
managers working closely with assigned providers is that, yes, we have a certain
responsibility to work with to reduce unnecessary admissions, unnecessary
utilization. We would certainly never prevent an individual seeking care at any
ED or hospital. We would guide and direct them to the right appropriate care, for
certain. But it’s really, it’s not a UR role, it’s a true case management role and it’s
that role that is really empowering and satisfying for nurse case managers to be in 131
that role because you really feel like you are in that full advocacy role and I fully
realize that UR has a place, not everyone can be in a hospital bed, skilled nursing
facility bed, or rehab not meeting any medical criteria whatsoever. You know,
people forget, health care is business.
And that’s OK, it’s a business, but we’re trying, what our role is in case
management to help deliver and help provide services that help deliver quality
and efficient care. You know care in the right setting for the right individual is
really in-. And we are always advocating for patients (PN, Personal
communication, December 3, 2016).
PN’s lived experiences at the time of the interview was as manager of outpatient care planning—more limited in scope of interventions but performing oversight to much broader groups of high-risk and high-utilization of services populations. Although it is part of a hospital network, the job is almost opposite in scope to that of the bedside acute- care nurses interviewed. This type of prevention-versus-intervention role did not exist before the 1990s. The ethics of contract obligations drive the selected interventions for large patient populations. Patients receive more encouragement to meet metrics (lab draws and medication compliance) than in following individualized complex care plans.
RN-CCMs in these programs have limited authority to go beyond the boundaries of established protocols. This reflects part of a health-care system’s effort to maintain distributive justice among different population groups. Pursuing exceptions above basic protocols requires significant time and effort from the RN-CCM. This can lead to a conflict between time management and the ethics of caring for individuals who need 132 more support in the outpatient setting. Most interactions are by telephone; interventions focus on certain high-cost, chronic disease populations identified by insurance analysis, such as those with kidney failure and congestive heart failure. The next interview reflects a similar oversight role in the context of the front-end non-acute RN-CCM.
Jeanne Good (JG): Identifying potential high-risk patients in computer reports. JG volunteered to be interviewed for this project after hearing my pitch at the professional CEU dinner meeting. We made arrangements by phone to meet after my interview with JC. However, due to cascading events—including getting lost trying to finding parking—I was twenty minutes late. Fortunately, I had notified her and she was willing to wait for me. We made eye contact in the small lobby. JG’s expression initially suggested a slight annoyance; we headed for the elevator, when JG instead suggested the stairs. Her spirits seemed to improve after my unhesitating agreement, as she escorted me quickly up the dark, gloomy stairway to her office in the oldest section of this modern and expanding urban hospital. Her compact, windowless office was remote from traffic and without ambient sounds, abundant with paper stacks and a few family photos. A simple lamp illuminated only her desk, which was half-consumed by a computer. A back counter and file cabinet were behind her rotating swivel chair. My chair was positioned in the corner directly opposite her chair with no furniture between us. I had the feeling the chair was used as a shelf also, but was cleared for my convenience. JG read the consent carefully and had no questions before signing. The implications of this brief beginning revealed a woman who assessed potential resolutions: If the elevator would take time, the 133 stairs would save precious minutes lost in my late arrival. My first impression was that
JG is a quick-thinking problem solver.
JG, in her 50s, appeared energetic and eager to listen and learn more about my project. She received her BSN in 1984 and has worked as a public health, oncology, and medical surgical nurse. Beginning in 1989 she started focusing strictly on labor and delivery; she has not done direct patient care in twenty years yet she works behind the scenes to make systems function more efficiently. In this way, she is similar to PN, although she has neither staff nor a specific roster of patients or protocols to follow. JG identified 1996 as her start in case management, when she was hired in the office of perinatal programs after working in the community setting. “I’ve been doing this before it was vogue” (JG, personal communication, November 18, 2016). JG passed the CCM certification exam in 2014. She is a member of the local case management professional organization.
Although JG’s tenure began as case management was experiencing significant changes due to managed care protocols, managed care insurance regulations in pediatrics and obstetrics historically have lagged behind adult care specialties. Clinical protocols in pediatrics and obstetrics are different from those in adult care. Furthermore, Medicare historically has been less involved with younger or pregnant patients. State-funded
Medicaid, covering low income populations, is more common in large cities. The
Affordable Care Act expanded Medicaid coverage, increasing the need for oversight strategies in predominately poverty-level populations. A twenty-year delay in certification may be explained by the exam’s content having less relevancy to pediatric 134 and obstetric populations. This becomes evident as JG describes her case management roles below.
Previously, JG was a telephone case manager in her current department assisting unique clinical concerns:
We have lactation consultants that are at the bedside. We have education. We
have all the tours, and classes—you know, childbirth education classes, sibling
class, grandparent class, breastfeeding class. We have all that under our umbrella.
And we use to have birth records—in fact, just got it taken out. They live next
door; they are all with us because all our patients use them (JG, personal
communication, November 18, 2016).
JG’s familiarity with her hospital and this department in particular has accrued over many years. She is knowledgeable about finding, accessing, and using resources.
JG’s current and unique role evolved based on her critical thinking and proven reliability working with rotating and permanent physicians and other providers. When possible, JG refers patients who have come to the emergency room off hours to geographically appropriate obstetric clinics or high-risk specialists. “Health care is ever- changing. You gotta do what you gotta do” (JG, personal communication, November 18,
2016). JG created her current role by observing a deficit in tracking high-risk mothers early in their pregnancy:
I have been in this role for three years. So, I’m called the community OB
[obstetric] navigator now. I was checking people that come into our triage which
starts at 12 weeks. I was…trying to figure out all those people who came there 135
into prenatal care so after I started in this role I said, “But what is happening the
six weeks before they get to triage?” So, we had a report built and now I follow
all the ED [emergency department] patients, trying to get them into earlier care.
They might be in the emergency department three or four times before they get to
twelve weeks, so we were missing that [opportunity], so that’s the part I’m trying
to get now: Getting them into care and with health (pause) what’s the word I’m
trying to think of, its escaping me … (sigh) .… Trying to start them into early
care. I guess population health, I guess. That’s one of the criteria that the managed
care [wants to] meet, where did the prenatal care start in the first trimester? So
that’s what we are trying to do, all across the board …. I am a referral source for
social work, so the domestic issues, I refer to preterm labor, I refer to the diabetes
case managers.… I’ll try to refer them to any resources in the community, like
WIC, Every Child Succeeds, all those different resources (JG, personal
communication, November 18, 2016).
JG finds her patients using electronic medical records (EMR). She is not assigned high-risk patients based on outside claim reports as other telephone nurses are. She uses her critical thinking skills and empathic maturity to find patients through certain aggregated details found in ED off-hour census reports and additional cryptic documentation; when she is sufficiently informed, JG notifies whomever she perceives as best aligned to assist the individual. JG is the link between these patients and professionals and an advocate whom the patient may never know. She has the authority to identify patients for the OB residents so they know to intensify medical interventions. 136
She identifies high-risk factors including newly pregnant, at-risk pregnant women who have a history of depression or other mental health or safety concerns, and notes made during ED visits on patients who may or may not be enrolled in one of several prenatal clinics in the hospital system to determine which clinic is appropriate for them to redirect routine care in the ED off hours. Her mission is to prevent premature or complicated deliveries. Her role is unique and expanding, as discussed below.
MM: Are you the are the only one in the WHOLE system [that does your job?].
JG: In the whole system. And it’s two systems, here and [Meadowview],
and Tedesco] and [Sunset]. So, I look at all those ED reports…I probably look at
120 people in the report a week. I would think something like that, and then from
there maybe I’ll have maybe eight to ten I’ll have to get into care…. So, I know
the patients in the end. And I’ve just been recently brought into the post-partum
visits. We are keeping track of our post-partum visits to make sure we hit, you
know, get these people back in, so I’ve been helping our IT people with that. So,
the names, I’ll go, “Oh, I know her! She’s been here a lot,” so that’s why I’ve
been pulled in (JG, personal communication, November 18, 2016).
JG details various ways she has an impact on patients, the clinical team, and the health-care system’s financial health. “I’m here ’cause I like what I do, I’m here because
I know if I affect one person, that’s a good thing” (JG, personal communication,
November 18, 2016). JG identifies positive experiences and the meaning of her role, including the autonomy of work hours, flexibility and professional independence, the satisfaction of facilitating patients into the right setting for prenatal care, establishing 137 trust that allows protocols to enhance patient care, and finding significant information that is not mentioned in recent progress notes. Assisting those who are not able to navigate the system holds meaning and reflects ethical values discussed in chapter two.
JG describes her role of advocacy other ways too:
We used to have to call the doctors all the time, they would never respond. They
never call the doctors anymore ’cause there’s always orders. The patient shows
up, and now I work so closely with the lab and they with me too and they can
draw the specimen instead of turning the patient away and call me for an order
and we’ll get the doctors to get the order. That wouldn’t have happened and that
should happen when we are trying to meet the needs of the patient (JG, personal
communication, November 18, 2016).
JG’s unique advocacy duties developed from her observations of the disconnect between care providers and patients’ needs and because of her working reputation within the system. The intervention described required a global view of how to facilitate patient compliance if obstacles prevented office-hour visits. Additional insight into JG’s scope of practice is found in her report of the benefits of her investigations of post-emergency room visit patient charts:
…‘[W]e’ll look at [the patient] in the emergency room but go back to [the clinic
location] where you belong.’ That kind of thing. But you’ll also see a lot of other
issues in there, you know, like diagnosis of anxiety or depression or they’ve been
hospitalized for suicide attempts or that kind of thing that I’ll go, “Well, now we
have so-and-so in our clinic, but two years ago she had this so I think the social 138
workers can follow up and find” kind of stuff in there….Oh it is great
[work]!…[T]here is nothing that flags these [patients]. That’s why it’s a lot of
intense just reading the charts and going, “Oh, yup, nope” (JG, personal
communication, November 18, 2016).
In another example JG addresses a lack of follow up after emergency room visits by sending post-visit letters to encourage patients to transition non-urgent care from high- cost emergency room encounters into lower-priced routine obstetric clinic visits.
The letter [written at 6th grade level] would say why prenatal care is important,
um, we can offer you these services, whatever, like I said we are just doing that
because now [administrators] are really looking at this.…I just saw a need after I
started this (JG, personal communication, November 18, 2016).
In addition to the letter, if a patient uses the ED and is assigned to a network OB clinic, JG notifies a social worker in her department or an appropriate clinic about the visit and any findings or overlooked notes concerning high-risk conditions. These examples of problem-solving and collaboration are all motivated by advocacy of caring for the patient to improve pregnancy outcomes in high-risk populations.
Two outcomes are recognized in part to her preventive contributions. One, “our
NICU is not as nearly as crowded as it used to be…[T]he ZIP code right around here had one of the highest rates of preterm deliveries in the country” (JG communication,
November 18, 2016). The other—organizational operations that include accomplishing quality metrics that are embedded in financial reimbursement contracts—is described below. 139
Our department is a bit, a little little little piece of the pie, so there wasn’t a lot
that people knew about us, just until recently when these post-partum visits got
interest because we brought revenue in.
MM: And you brought revenue how, by the lab values?
JG: No, no, not just me, our department.
MM: And how did they…
JG: ’Cause we increased post-partum visits that people came in. And
managed care was looking at them.…[N]o one knew we were here until this
initiative started and all of the sudden, when administration asked, “Who can do
this?” and we were the people. And that’s what we did, but we REALLY needed
to do this so it was money drive.
MM: So, it was financial, too.
JG: And now it’s like, oh, there’s a lot of people in that department and
they can help us. That’s a really good change that we are being recognized for all
the work we do. I work with a lot of great people (JG, personal communication,
November 18, 2016).
In this example, JG experiences being recognized by others for the beneficent work. She perceives this action as positive for the patient and for the department overall because of the financial obligations needed to maintain department financial contributions and avoid cutbacks.
However, when JG conjured up efficient revenue enhancing and tasking- relationship types of changes requiring computer software programming, JG experienced 140 less collaborative responses from others. JG describes being employed in a large slow- moving hospital system in which change can conflict with culture (turf). Efforts to improve change outcomes, as the previous example suggests, requires changing tasks to meet contract reimbursements and pay-for-performance metrics. Because of her successes, JG is now expected to expand her role in identifying high-risk pregnancies to include commercial managed-care patients and the increased number of Medicaid patients under the ACA. Her current computer report does not and cannot provide the necessary chart data to make that assessment, and programmers are unable or unwilling to change the current software to create an adequate report:
It’s archaic, but we have [Energy Programming] so I have, we have a list on
[Energy] that I share with the doctors. But we still have paper because we went to
Madison, to [Energy], in Wisconsin, and we said, “Hey we want to populate, we
want our labs to populate because this woman’s going to come in every two days
or three times or 6 days, or maybe, whatever, she can get a ride or whatever.”
Uhm, and they are like, “Well, that’s never going to happen.” So, we have to
manually have somebody look—“Did they come in?” and then invent a new plan
or “Well, this is what’s happening,” you know, so I do still walk around with a
book like this (JG, personal communication, November 18, 2016).
The lack of programming flexibility to meet increasing need affects JG’s tedious task of finding “core hunches of critical information…buried in the note” (JG, personal communication, November 18, 2016). Therefore, her work process is less efficient if more patient payers are to be included in her daily scouting tasks. She has requested more 141 nonclinical assistance to meet organizational pay for performance metrics. It is significant that JG is the only nurse performing this identification task. Migrating into more management duties creates a potential relation-task conflict because this change requires more training, as well as trusting others’ reliability and identifying outcomes that value advocacy for the patients. Trustworthiness is a similar concern for BH and CM, although the external variables are different.
Increasing and changing scope of practice cause another concern JG experiences as turf issues embedded in the hospital culture. Turf issues are characterized by a) relational task-type resistance from clinical areas to participate (example below) and b) perceptions of isolation increased by lack of awareness or concern—perhaps even some jealousy—from other employees about what her job entails and the benefits to patients because of her interventions.
I have reached out to the emergency room because I wanted that [census] report
actually to have the nurses to say, “You have to answer these questions.” Uhm,
but couldn’t do a lot, you know, because it’s not my department so we, you know,
just try to educate [everyone] a little bit, as I would like.…[The ED director]
wanted me to do it all; she wanted me to call each nurse up and tell them they
forgot to do that. I don’t have time for that. The ED director [who is not my
director] said, “You can educate my nurses,” and I’m like, I mean, it was like, it
got out of hand. They were like, “Who are you?” I have no business doing that so
I told my director, “We’re not doing that anymore.”…If the ED does a pregnancy
test, they just do it. I’m drawing [reports of census data] anywhere for 12 to 55 142
[years of age] or something. If they do a pregnancy test, it’s going to hit that
report. So, we’re anticipating, it hasn’t happened yet, probably within the next
couple of weeks, my report is going to double [due to increase in covering
commercial and expanded Medicaid populations]. So, I don’t know what’s going
to happen [chuckles] (JG, personal communication, November 18, 2016).
JG’s situation is challenging. Her perception of what is best for the patient in the long run was perceived by others as an additional burden of duty on staff whose time is closely scrutinized. The conflict regarding others’ time management caused a conflict based on perceptions about what tasks are necessary. This illustrates task-relation conflicts that are further explored in chapter five.
Ultimately JG enjoys the challenges of finding initially obscure high-risk cases and thereby preventing or mitigating potentially high-cost complications later. JG’s ability to anticipate is based on her clinical expertise, empathic maturity, and reputation.
Her personal confidence and the respect bestowed on her by the medical team and administrators gives her autonomy to pursue advocacy in unique and unobtrusive methods. The result of her ethical and empathic advocacy is patient satisfaction and aligning care with financial metrics.
Although JG’s autonomous task of investigating records allow her more independence, it simultaneously creates more isolation. Applying critical thinking, empathy, and emotional intelligence, JG identifies potentially serious and underreported conditions illustrated in the discovery of previous maternal suicide attempts. Completing more complex practical duties and interactions with others involves changing established 143 procedures. Working with other departments creates conflicts that are not easily negotiated within established silos and hierarchy. JG’s perception about Medicaid patients having less and their unborn children deserving equal access to safe pregnancies reveals advocacy supported by ethical principles of distributive justice and non- maleficence. In the final working biography the case manager has far less autonomy but an equal sense of compassion for the less fortunate.
Marie Crumb (MC): “Seeing” with a mind’s eye using only the telephone.
MC attended a professional meeting of case managers during which I made a pitch to find potential participants. She clarified and confirmed the criteria with me and then signed the phone contact list. Two weeks later I called MC (at her request, in her place of employment) and set up an interview time. She asked me what school I was attending and what degree I was seeking. These actions reflect MC’s cautious, thorough inquiry to ensure confidentiality and authenticity. The day of our scheduled meeting I arrived five minutes early, and texted MC as she had directed. She texted back that she had gone to the hospital to see some team members and was on her way back via the hospital shuttle.
I waited outside the front entrance and saw what appeared to be business or administrative persons walking from parked cars or disembarking from numerous buses; no nursing-attired people or obvious patients were entering or exiting the area of the main entrance protected by an overhang and under which I was positioned. MC arrived 30 minutes after our text communication. She apologized and gave no urgent reason for her delay, stating with a slightly wry smile in reference to the meeting she had just attended,
“People need to talk a lot” (MC, personal communication, November 18, 2016). The 144 routine of commuting to the hospital when conducting business suggests the organization tolerates an on-duty, sixty-minute round-trip travel time deployment for required face-to- face work. This may imply she does not travel off-site often. I observed several shuttles arriving and departing in those 30 minutes, apparently heading to and from different destinations. The building was a renovated hotel and appeared to be occupied solely as a satellite building for the hospital for which MC worked. This off-site building-bus service scenario is common for expanding large city hospitals with limited real estate near the acute-care hospital.
MC was dressed in generally understated, not trendy, business casual attire of a loose tunic top and shirt outfit, casual walking shoes (not sneakers), with an ID on a lanyard that she swiped to unlock the entrance door. Makeup was simple, if any. She had short-cropped blonde hair and a fair complexion, a slender athletic build, and walked at an energetic pace. She smiled spontaneously and often. We traveled up an elevator to the fourth floor of the office building. The floor we entered had about twenty cubicles each about eight feet by ten feet with computer, printer, and reference papers pinned on the padded partitions. Sound was muffled, the atmosphere business tone without background sounds (radio or music), and eye contact was limited as we walked past to the conference room MC had reserved for our conversation. The conference room was about ten feet by twelve feet with two slender tall windows looking out onto a transitional neighborhood with renovated large homes and building construction.
MC’s initial interactions indicated curiosity and unfamiliarity with being interviewed. MC had talked to me for five minutes at the local chapter of professional 145 case managers; she had less awareness of my background or longevity as a case manager.
As the conversation unfolded, she became more at ease in describing the context of her tasks. As the interview progressed, MC used her hands in various gestures—at one point holding her hands together and tapping the table, another time sitting on them and sometimes resting (not often). She kept steady eye contact, other than the times when she looked out the window or down at the table (mainly describing her personal life circumstances with a long-term disabled adult son and her active, thriving daughter). She smiled easily and made every effort to answer my questions. Mostly she leaned back in her chair and seemed open to the process. When the interview was over, we left together and she escorted me to the front lobby, shook hands, and offered to do the interview again if the recording did not take (a concern surfaced about the microphone halfway through the interview).
MC obtained an associate degree in 1987 and a bachelor’s degree in nursing in
1997 from a local college. Now in her mid 50s, MC has worked her entire nursing career in pediatrics and neurology. She holds a pediatric nurse certification. She has been employed as a case manager for five years and passed case management certification in
November 2015. By that time, managed care had become deeply entwined in health-care management; managed care reimbursement and protocols had siphoned off much of case managers’ autonomy. This is evident from MC’s reflections about her role as a population health telephone case manager for the Medicaid pediatric population. Children on Medicaid have multiple social and physical limitations which impede caregivers in maintaining continuity of keeping appointments and comprehending instructions given to 146 them by numerous specialists. Personal disclosure: My insight of pediatric population oversight was obtained during the mid-1990s as a case manager for a private insurance company. At that time I was assigned to telephonically monitor 80 chronically disabled children whose parents could afford commercial insurance, but needed help navigating certain services such as feeding tube equipment and liquid nutrition. Similarly, MC’s job is to track and intervene when appropriate, as samples illustrate below. MC monitors home routines by collaborating with the specialist offices, determining the treatment plan ordered, and how it is interpreted by caregivers. Her current position on the population health team began two and a half years ago as a result of the increased management with the Accountable Care Act risk pool. Her team is an interdisciplinary peer group composed of a social worker, community health worker, and three nurses located physically near each other and within easy reach of other, similar teams with whom they share information.
MC’s duties are contacting patients, assessing unmet needs that may affect the child’s health and treatments, and following up with specialist offices if changes are needed or with outside vendors if appropriate. Her daily routines include tasks and interdepartmental communications:
So [the morning team meeting is] an informal huddle just to talk about that day.
So, and then, for me and the other nurse case managers as well, typically you are
at your desk doing telephonic case management. On any given day I may have a
meeting because we are working, currently working in some projects, for instance
with our collaborative efforts with the hospital care managers who are in the 147
primary care site, so we are trying not to duplicate work and merge some of our
services with some of the changes with Ohio Medicaid coming up. So sometimes
I may have a meeting there. Sometimes I may go meet a patient at the hospital or
in the community. Primarily most of my day is spent in the office working
telephonically, with case management.…
MM: So, you use computer software like [Energy] programming?
MC: Yes, [Energy] and we also document in…We just started to
document in Energy minimally, but we use something called V Care. It’s, um,
through Valence, who [Hardy] Hospital contracts with….agency V does
utilization management for Melina and Paramount, and um, so we use that
software (MC, personal communication, November 18, 2016).
MC monitors home environments and physicians’ care plans for pediatric populations. In contrast, participant PN’s role is training outpatient nurses to meet insurance benchmarks for payment metrics in chronic illness populations. MC has far more direct patient contact compared to PN. JG and PN both appear to use their knowledge to improve processes that are aligned with patient compliance under managed care contracts—a “same church, different pew” contrast.
Regulatory rules are modified routinely. Duplication or lack of data collection is contentious for MC in the hierarchy of siloed department processes that indirectly affect reimbursement. MC experiences problem-solving in data collection, retrieval, and the communications required to ensure staffing efficiency, even if the outcome is that her 148 position is becoming redundant. Team collaboration is also required to keep flexible working hours:
Often people cross-cover part or full days. It’s nice because some of the nurses
have flexibility and prefer to work ten hour days, four days a week in 10-hour
shifts, and there is also flexibility in this work where if I need to leave work a
couple of hours early, I can make the time up another day. We also have
flexibility in that we are allowed to work remotely at least twice a month, at least
two days a month, at least ten per cent of our FTE, but sometimes that can be
flexible if there are extenuating circumstances like medical appointments or
whatever. Just to keep us productive, whatever keeps us most productive (MC,
personal communication, November 18, 2016).
MC describes a relatively predictable job tracking high-risk cases that includes sanctioned flexibility with no weekends or holiday hours. Her duties are based on protocols of oversight to reduce avoidable exacerbation of high-cost chronic disease. She participates in interdisciplinary and interdepartmental collaborations; schedule flexibility is a highly valued employee benefit. The job aligns with her personal values and meaning-making of case management.
MC described her case management role on a team as providing successful support and advocacy with quick limited interventions such as taxi vouchers to reduce no-shows at office visits due to lack of transportation. Below, MC recounts a time when she applied for funds and presented her case to a special hospital committee. 149
[There’s] a committee called “the social investment fund.” So, OK, this mom
needed help paying her rent this month. Can we help her with that? So, there’s a
social investment fund that looks at “how is this going to help with this child
reaching health care goals.” When the committee meets, it’s determined. “Yes,
this meets as a resource, we can help this family.” Then they go back and look at
it a month or so later and say, “OK, so now, where are they now? Are they in a
better place than they were before that resource?” So, it’s a resource that is there
but as I say, it’s thoughtfully given and we have shown we’ve made a
difference….If they are homeless and can’t access a homeless shelter because
they have a child in a wheelchair that’s not wheelchair accessible and this child is
medically fragile, OK, so you can help this person get into a hotel for a month
until they can get into this permanent housing situation. And so that would be an
example, maybe of what the social investment fund could provide (MC, personal
communication, December 18, 2016).
This advocacy action required considerable effort and was outside of MC’s routine work duties. MC chose to take this extra effort to advocate for this child and mother. MC spoke of another rewarding outcome revealing her proactive and patient- centered efforts to assist caregivers with complex home treatments and multiple responsibilities:
Oh, the mom had so many health issues. She had three children on medications,
and she has no way to get to the pharmacy so she has not been able to refill the
medicine. So, one has epilepsy and needs seizure medicine so we found a 150
pharmacy, this Walgreens. I learned something. Some Walgreen pharmacies
actually deliver to the home. So I’m thinking, we are going to have to find a
pharmacy that delivers. I’m talking to the Walgreen she uses to see if they are a
pharmacy that delivers, because she has had a really hard time being able to get
her pick up her prescriptions and they said, “Oh, we deliver.” “Oh, how do you
set that up, let’s do that now!” (MC, personal communication, November 18,
2016).
When viable solutions require additional administrative action, MC takes action by communicating and collaborating with others. Her problem-solving ultimately prevented potentially high-cost complications. Beneficence, a process of compassionate inventions such as this, depends on clinical expertise and emotional intelligence when communicating with others.
Verbalizing her motivation in this work, MC aligns her ethical standards to inform advocacy. For example, MC offered the following perceptions about her current case management position:
I find it rewarding, it might sound corny but I really do like to help people reach
their goal and be successful and be able to help them out. For me it’s very
satisfying as a person and in my career to do that, you know. (active hands). Like
I feel very, very fortunate to work in a field and a career that I really do like, you
know, so, you know lots of people have jobs that they don’t like and they have to
do it eight hours a day, forty hours a week. And I don’t have to, not that I don’t 151
like to stay home sometimes, but I really do like my job! I like what I do! I’m
generally positive person (MC, personal communication, November 18, 2016).
MC enjoys her specialty and values the self-worth that results from the ability to decide when and how to pursue extraordinary and compassionate support.
However, the majority of MC’s high-volume autonomous auditing requires less complex interventions. Her specialty experience and critical thinking skills include preparing succinct, clinically knowledgeable reports for each patient chart she reviews.
Each report is typed and then cut and pasted into two separate clinical computer systems.
Performing these tasks is a type of organizational advocacy providing vital interconnectivity affecting everyone. Tasks unique to this telephonic case management role appears to yield nonurgent problem-solving interventions. Consistent with other RN-
CCMs’ jobs, high-level interpersonal communication skills are essential to elicit, verify, and efficiently communicate between lay caregivers and specialist office staff.
MC’s autonomous processing tasks (chart auditing and documenting) do not generate conflict in themselves. MC does not report her relational tasks as frequent face- to-face interactions. Most communications are through computer progress notes and telephone conversations. This eliminates the ability to observe nonverbal communication, which can be a disadvantage during navigation and collaborative mediation. MC identified relational task conflict as turf issues with a specialist’s office staff that may result in her telephonic job being merged with specialist or decommissioned all together, depending on the health-care system’s administration assessment to be determined in the near future. MC describes the situation as follows: 152
So, our primary-care sites here at Hardy takes complex care, CPC, they are in the
process of becoming their own medical home, which is the best thing for the
patients. Now what that’s going to do for us at HPCC is gonna dwindle our needs.
We are not going to be as necessary in our current state. We’re going to be
changing. So, nobody really knows what that is going to look like because a lot of
the children we case manage now, that’s going to be done by the primary-care
sites for their primary contact, as I say, as it should be. We have all of their needs
integration work and that is what is kind of all moving towards. So, what that
means is that like two years from now, a year from now, my cubicle may not be
right over here (laughing). I might be somewhere else as the other nurses
too.…(pause) [That feels] a little scary? But it’s like I tell myself, I knew this was
a changing environment. Health care is anywhere but especially here, really
changing. Like I tell my husband, “Oh wow, guess what I just found out today?
There’s going to be some really big stuff coming down with what these changes,”
and he’s like, “Oh well, that’s life,” something like that, and [I say] “You’re right!
It is” (laughing) and you’ve got to go with it. That doesn’t mean it isn’t
stressful.… (MC, personal communication, November 18, 2016).
Anticipating the loss of her livelihood due to system changes conjures in MC a type of conflict. Separate from codes of conduct, change is ubiquitous as hospital systems respond to regulations created by government payment structures such as pay-for- performance metrics. MC stated that her current telephonic role was the hospital network’s response to a rapid increase in Medicaid disability patients who required 153 intensive proactive monitoring. The payment structures created the context in which conflict of change is inevitable.
Summary
This chapter introduced as a group and individually the RN-CCM volunteer participants. Common interests in maintaining self-care activities were perceived as valuable and replenishing to the individual. The texture of daily work interactions informed selected self-care activity. For example, a desk job inspired stair walking or horseback riding as stress relief or an acute-care setting inspired stationary activities such as reading.
Although the group presented a wide variety of educational and clinical backgrounds and working environments, participants demonstrated similar perceptions of ethical practice-based on codes of conduct and motivations for advocacy. They are employed in various patient encounter locations including telephone, clinic, emergency room, acute care, and special practice and network management offices. Actions based on the value placed on caregiving and advocacy varied for several reasons, including perceptions of agency or duty in their role, variable length of time on the job, and intensity of engagement with patients.
Participants identified problem-solving events as highly valued process work.
Two consistent meaning-making perceptions RN-CCM had about their roles were the meaning and value attributed to their personal contributions as a patient advocate and the value of performing their job duties effectively. Other meaningful attributes consistently offered by participants included the meaning and value ascribed to peer support and, 154 conversely, the lack of collaboration across silos of care, including outside providers.
Direct communication with patients or providers varied in frequency and intensity and reflect individual proclivities for intervention and tolerance of fast-paced care environments. For example, MC has a large caseload and tracks progress over time in an office 30 minutes from the hospital; KF and BH have a fraction of MC’s caseload with intense interactions inside the acute-care hospital and a duration of contact limited to the acute-care stay; JG has almost no patient contact, works in a secluded office with no windows or pedestrian traffic, yet creates effective patient-focused protocols to ensure blood monitoring and efficiently refers high-risk charts to other professionals for intervention.
Lived experiences describe scope of practice and contributing influences in decision-making, and therefore offer insight on research question two. In particular, perceptions about scope of interventions and authority in decision-making were heavily influenced by the context of health care organizational protocols and expectations to deliver cost-effective (staying in network), safe (meeting regulatory standards), and standardized vs. individualized care (limitations of computer templates vs. ethics of caring based on individual needs).
Despite system-imposed limitations in decision-making, each participant valued their advocacy role based on their personal attributes for certain caregiving specialties, regardless of venue contexts (telephonic or acute bedside) or depth of direct patient interactions. In this chapter, repeating conflict themes and dominant personal attributes 155 such as expert collaboration, problem-solving, and decision-making further define RN-
CCM experiences.
156
Chapter Five: Emergent Themes
This chapter articulates themes emerging from lived experiences that reveal influences of Other limiting or supporting the RN-CCM’s authority to advocate.
Interventions in this chapter require significant self-determination, problem-solving, and collaboration. Two significant findings are highlighted in this chapter. First is the phenomena of conflicts experienced by every RN-CCM, including risks of moral distress, and, second, the meaning of certification primarily as a self-care endeavor. The final section is a discussion of the findings and implications for future research.
This chapter has eight sections. The first five sections concern emergent themes of conflict and include an introduction, three sections describing conflicts, and one section on risk of moral distress as a result of conflict. Sections six and seven address the
RN-CCMs’ meaning of certification, a summary of these findings, and section eight is discussion and implications. Each emergent theme of conflict is a separate subsection in which excerpts and supporting literature give breadth and depth of RN-CCMs’ lived experiences revealing these themes of conflict. The descriptions of emergent conflict themes are followed by descriptions of the observed attributes useful in processing those conflicts. Section eight contains both a discussion of findings and implications for further research. Table 5.1 outlines the three themes of conflict as they emerged through experiences described by participants. They will each be described in detail in this section. These themes emerge from coding the transcripts of narratives based on literature in chapter two addressing ethical principles and personal attributes. Themes emerged 157 when content exemplified the defined bioethical principle(s), virtuous action, and personal attributes of empathy and emotional intelligence.
Table 5.1.
Emergent Themes of Conflict for RN-CCMs
Types of Conflict
Change Tasks and Relationship Caring
Management & staffing Technology vs. face-to- Critical thinking resignations face collaboration compelling advocacy
New technology Incorrect, omitted, Evidence-based insufficient data causing decisions informing delays in planning & preventive plans affecting patient outcomes
New responsibilities Turf conflicts and Unsatisfying outcomes hierarchy on deciding are consequences of priorities conflicts to self, patient organization (Risks of moral distress)
New reporting mechanisms Financial restrictions to best providers for patients
158
Conflict: What It Means and Why It Matters
Conflicts arise a priori in health care and are not always dramatic.
Conflicts arise when polarized responsibilities are embedded in changing protocols. Protocol changes are driven by management—creating efficiencies such as requiring the use of computer templates for communicating information but simultaneously diminishing intelligent, nuanced collaboration—and therefore create burdensome problem-solving processes and work-arounds when advocating for patients.
RN-CCMs’ experiences of conflicts are complex because their jobs are complex. RN-
CCM are problem solvers and collaborators who often face conditions they cannot control or mitigate. This phenomenon of experience creates conflict which each RN-
CCM accommodates differently.
Three prevalent complex conflicts emerged within RN-CCM roles are a) conflicts of change, b) conflicts of task-relationships (protocol driven), and c) conflicts of caring
(problem-solving unique to RN-CCM code of ethics and experience). In addition, the existing empathy and EI developed in each RN-CCM influences how they perceive meaningful intervention identified as conflicts of caring. For example, BH is outspoken on the job, CM withdraws from confrontation, and PN chooses a temporary assignment to help the network meet financial goals.
Conflict pertaining to health care contexts has many definitions (Kelly, 2006, p.
22). For this inquiry into RN-CCMs’ roles, conflict is defined as “an awareness by employees involved in the conflict that discrepancies or incompatibilities, wishes or desires exist among them” (Jehn & Chatman, 2000, p. 56). “Conflicts can also involve 159 opposition or differences of opinion, priorities, roles, beliefs, perceptions, practices, authority, and values during in conflict situations” (Warner, 2001, p.16). Wright, Mohr, and Sinclair (2014) found
specific qualities and meaning to interpersonal conflicts between nurse and other,
primarily other nurses. Themes of interpersonal conflicts coded from interviews
include feeling unfairly treated, animosity, others’ responsibility or competency,
lack of communication, difficult work structure disagreements and unsolicited
instruction” (p. 32).
Interviewed RN-CCMs’ lived experiences also contain these themes of conflict daily, maybe hourly. Literature affirms that conflict is “inevitable in any work environment due to inherent differences in goals, needs, desires, responsibilities perceptions and ideas. Persistent conflict is detrimental” (Almost, 2005, p. 444). To sustain employment when subsumed by conflicts, maturely performing RN-CCMs appear to combine moral rules and virtues with personal styles of empathic maturity and emotional intelligence, all of which are defined in chapter 2. These moral rules and virtues are implicit in written professional codes of conduct. Styles of empathic maturity and emotional intelligence promote integration or acceptance of other views and allow for collaborating in group decisions made during problem-solving. Moral virtues and personal styles impact conflict management styles. Also relevant in experiences, as mentioned in chapter four, self-care activities may stabilize self-worth and meaning, although this observation would require further research.
Jehn & Chatman (2000) report that consequences of the “composition of conflicts 160 can impact performance” (p. 57) . According to this research article none of these conflict categories exist as isolated experiences in workplace groups and among group members.
Almost (2005) believes “this experience may possibly result in “[j]ob dissatisfaction, absenteeism, and turnover” (p. 444). These insights are useful in defining conflicts that emerged and are applicable the research question concerning conflict. Each of these predominant conflict themes identified have certain qualities common to each RN-CCM, as illustrated in the remaining sections of this chapter.
Conflict of Change
The researcher’s observation of interview content and literature (Jehn &
Chatman, 2000) confirm the impact of relentless change as a cause of conflict between self and other.
The pace of change in health care policy is significant with the introduction of the
Affordable Care Act (ACA) in 2010. These policy changes are responsible for
rapid changes in the clinical practice environment. Seismic shifts have occurred in
the Medicaid enrollment with uncertain implications as to how health care
systems will respond.…An illustrative example of the collision between medical
practice and policy resides in the lagging updates for performance measures that
are used by most health policies to measure quality of care (Laiteerapong &
Huang, 2015, p. 849).
Although all participants perceived theses “seismic” changes, the way those changes impacted the RN-CCMs’ processes, relationships, and tasks in 161 organizational contexts and created conflict was experienced differently because case management duties varied across the network.
As employees, RN-CCMs must adapt, without contributing a voice, to rapidly changing priorities in health-care politics and reimbursement criteria established by those who do not work on the front line with patients and providers. For a patient advocate, trustworthiness requires establishing a relationship, applying interpersonal skills, and understanding the limitations of policies limiting interventions. The ability to skillfully navigate among expectations is a meaningful contribution requiring experience, emotional intelligence, and empathy to preserve a positive self-perception if outcomes are not satisfying. Maintaining trustworthiness as an employee and as a patient advocate can generate conflict. Decision-making that mitigates conflict holds meaning for these participants and requires knowing how the system works and problem-solving on behalf of the patients. The implications of phenomena on conflict on the study include how the
RN-CCMs may experience conflict differently and not label the experience as conflict.
The experience of a situation may require accepting the dissonance as an expectation of the job or perceiving it as unavoidable. Alternatively, RN-CCMs perceive some conflicts as resolvable with concerted effort; some conflicts are perceived as annoying alone, but in the aggregate as creating obstacles to precious time that could be spent focused on quality patient assessment and advocacy.
In these interview examples, change caused a) confusion in task-relations and process duties illustrated by losses of job or management leadership, b) dissonant routines of communication, and c) re-definition of the scope of practice, documentation, 162 and potential interventions. Conversely, change brought new or increased organizational projects aligned with reimbursement rules, compliance regulations, and challenging quality measures with financial metrics. These changes can be perceived as positive for the institution’s financial stability. Participants assigned meaning to these changes because they reflected on them spontaneously in open-ended questions. The implicit conflict of change between the change itself and the participant is the impact on workflow routines, time management, access to resources, and, not least, one’s sense of purpose as an advocate because automated systems reduce human interaction. For many of the RN-CCMs, human interaction in decision-making is a meaningful activity. Also, constraints on financial and human resources, shifting power gradients among groups, and shifts in health care policy contribute to broader conflict due to changes embedded in the hospital network organization and are outside the scope of the RN-CCMs’ influence, although they affect the context in which the RN-CCMs work and therefore add a portion of meaning to assigned tasks.
For MC, task-relationship conflict regarding a specialist’s hierarchical position impacted her current job so that it may be phased out and her patient tracking efforts subsumed into a more politically powerful specialty practice.
… our whole work with integrating with the teams over there, it’s change, and I
get that. It’s change and everybody responds to change differently. Change isn’t
easy with everyone and some are more open to it than others. And I think that is
where a lot of that comes from; again, that territorial kind of feeling that some
people of saying, “We are managing this person and you butt out.” Those aren’t 163
the words that are used, it’s kinda like that. So, it’s a little dicey so you have to be
diplomatic and include them and all the while meeting the needs of the family
because they are the priority. It can be a little bit challenging because it’s not like
any one of us here are the Lone Ranger as far as the case manager. We are a team
approach and we do have our management support and then the hospital side
where everyone is trying to come together to come up with one model of care so
we can meet the needs of all of these families(?). Um, and I’m not comfortable
with that work, and nobody wants to do that (MC, personal conversation,
November 18, 2016).
MC acknowledged change based on the difficulty of change when assigning responsibility among different departments. JG, on the other hand, acknowledged that a change in management brought a similar conflict between different interdepartmental protocols. Two examples illustrating conflict of change emerged for JG: First, she experienced increased organizational expectations and accountability for her investigation of charts for high-risk pregnancies coming through the emergency room during non-clinic hours. Second, JG reported directly to a manager who recently left, so now she has less independence and less support from others and. JG’s tasks are not well understood and may lack meaning for her peers but not to the clinical and financial leaders in her department.
It used to be more flexible when I had a manager. But when I don’t have a
manager it’s not as flexible.…She didn’t care, she was like, “You have a job, you
get the job done,” I mean, ’cause I always work, I’m always here more than 48 164
hours, so she was like, “I don’t care when you work” (JG, personal
communication, November 18, 2016).
The loss of management support is meaningful for JG because her job is independent of team support. These examples of change manifest phenomena of conflict for JG because she values and makes meaning of having leadership and guidance.
Similarly, another participant, MJ, mentions changes resulting in a lapse in peer support.
So, I used to go to the nursing director who, she recently left, and um, kinda we’re
in flux with transition team. So now there’s really no one that I feel I can go to
with, especially like I use to go to with, like I use to go to this person (MJ,
personal communication, December 1, 2016).
This implicitly suggests a conflict in relations based on changes in trustworthy peer support. The outcome seems to be a sense of isolation, which could cause a risk of low performance and moral distress.
In HR’s rapid, abbreviated reflections she included one example of the obstacle- lade process for obtaining approvals for equipment:
So much going on with durable medical equipment we have to do to provide
them. To get the patient a wheelchair or to get them transportation, it isn’t easy
anymore. It’s very time consuming. There’s paperwork documents, you have to
track down the PCP, they are not always here in the clinic (HR, personal
communication, December 1, 2016). 165
This comment gives meaning of the increasing burden from the past when there were fewer regulations around the medical necessity for high-cost equipment. As approvals have become more complicated, conflict has emerged over the value of communicating data versus the needs associated with collaborating or problem-solving. If the task does not require professional contributions, it becomes a burden and therefore has less value for the RN-CCM than, for example, participating in a patient conference.
Similar to changing protocols perceived as initially complicating to HR, KF perceives an increase in workload as a change that requires more effort:
Just in the last year or so, just in the last year the volume has really increased and
I think it’s just hard for people to just keep the people’s head above water
now.…People have been picking up… most of the assignments are on Medicine,
typically you can have one pod which can be 15 people, depending. On Oncology
they cover two full pods which can be very challenging. And [Greenstein], like I
had all [Greenstein 12] today, the whole floor, so you’d cover both sides. And like
[XYZ] building we’d cover two floors at a time. So, people, their volume is up,
say at least twenty to twenty-five (KF, personal communication, December 2,
2016).
As with KF, CM experiences a conflict of change in staffing: “There has been a lot of change in the workplace so now we are in a very serious situation with people very unhappy with nobody assisting them, we have no educator, nothing” (CM, personal communication, December 3, 2016.) 166
For JG, KF, and CM, the conflicts of change are easy to identify. PN identified migrating projects, rather than staff, as meaningful. She was encouraged by management to accept a position overseeing a large start-up program, thereby adding to her job responsibilities. In the following statement, she reveals an implicit conflict that emerged based on the instability of current initiatives and the meaning PN assigned to being a trustworthy employee.
So right now, at this point in time, right now I work directly with the care
management leadership and three affiliated units that are part of our integrated
health-care system to address a number of components. One is staffing policy and
procedures, um, training, education, standardized care that includes evidence-
based practice. And I do want to say too, that right now, it’s not going to be a
long-term plan. I am actually also working to build, we are just ramping up to
start this the first of the year, overseeing a self-insured population program that I
was asked to develop with my boss. The job that I am in right now I have just
been since August. So, it hasn’t been a full year even. So temporarily we are
building, as far as nurse case management is concerned, I am going to be
working, training, and, um, mentoring the population health network care
managers that I work with, the self-insured population as a temporary basis, right
now, I’ve been asked to supervise (PN, personal communication, December 3,
2016). 167
PN’s oversight and program outcome goals were not revealed in many detailed measures. She mentioned projects that seemed significant, although measurements of success or failure were not defined in the interview.
BH’s experiences as a front-line worker showed how implementing management projects can change perception of the meaning of effective advocacy for an RN-CCM. Of note, BH has performed case management duties for thirty years and found the current downgrading, for whatever reason, of independent collaboration demeaning.
We used to report to the physician hospital organization and three months ago, we
are now reporting to the Department of Nursing.…It’s sad that we have gone from
a professional model back to the UR discharge dark ages (BH, personal
communication, December 3, 2016).
BH identifies the UR model as being less autonomous than the professional model of his earlier roles. In the quote below BH further reveals how the RN-CCM role has changed by explaining how time is spent communicating with practice site case managers:
[There is] an increasing trend over the last five years. Ah, we never used to get
cases, but now we are getting calls, “This is Mary from the Primo PHO or
Secondo PHO.” We are even getting called from case managers in the CUE
system. It’s time consuming (BH, personal communication, December 3, 2016).
Change affected both the amount of time these case managers spend performing tasks and the meaning they assigned to the tasks themselves. 168
The consequences reported by these participants reflected increasing frustration, perceived isolation, and low-level tasking. Literature confirms these are the consequences of conflict in the workplace (Almost, 2006; Eason & Brown, 1997). The reality of change creating conflict cannot be mitigated directly by employees; organizational relationships are system-wide initiatives and beyond the scope of this qualitative research. What can be useful in understanding the meaning given to change can be introduced in a workshop addressing conflict of change. For example, recalibrating activities, such as meditation, may ameliorate increasing pressure to perform to standardized metrics. These are unique to each individual in self-care actions and merit more study (Baer, 2009; Cohen-Katz,
Wiley, Capuano, Baker, & Shapiro, 2005).
Conflict of Tasks and Relations
In this section task, relating (communicating) to others, and task-relationship process are each are defined as components of the job. Jehn and Chapman (2000) investigated how task and relationship influence the work environment. In general terms:
Task conflict describes disagreements about the work that is being done in the
group… Relationship conflicts involve disagreements based on personal and
social issues that are not related to work [such as cohesion and commitment].
Often intertwined with tasks is relationship conflict… Proportional relationship
conflict composition is [defined by the authors as] conflict in social groups
characterized as an interplay of task, relationship, and process (Jehn & Chatman,
2000, pp. 57-59).
Participant RN-CCMs revealed these conflicts when describing collaboration 169 around transmitting data. The conflicts combining relationship and task (relationship-task conflict) are relevant to this inquiry because RN-CCMs collaborate with many others as part of their scope of responsibility, and the conflicts that ensue involve multifaceted variables beyond a functional task. The meaning of these conflicts is not ethical per se nor only practical. These conflicts have meaning in the high value assigned to effective processing skills to perform as advocates.
The RN-CCM does multiple tasks depending on the job context. As stated, tasks are not perceived as conflicts by themselves. Tasks requiring interactions and reliance on others can become conflicts.
CM, an acute-care RN-CCM float, described conflict in this definition of tasks, including starting the day at 8 a.m. with computer rosters of newly admitted or newly assigned patients. Each patient must be prioritized complete with risk assessments, required scheduled tests for acute conditions, or facilitated discharge before a 10 a.m. computer documentation deadline. Acuity levels entered into the computer depend the
RN-CCM’s judgement, using available data that is not always accurate. The software is the repository from which the RN-CCM extracts data from multiple chart locations and informs administration and financial parties to establish an accurate reimbursement level.
Performing these tasks efficiently requires proficiency in identifying relevant clinical details, such as a specific titrated lab value or reported vital sign that will meet reimbursable acute level care, and communicating accurately with others who have varying levels of clinical understanding. The RN-CCM who makes this aspect of work look easy is an expert in clinical knowledge and computer systems. When systems 170 change or do not communicate with other systems, the RN-CCM duplicates tasks. This is not perceived as a problem or conflict in itself. However, it takes time away from other pressing, more meaningful experiences; for this reason, it represents a conflict for the
RN-CCM to problem solve and reprioritize attention.
In this project, task-relationship has meaning to the RN-CCM when values between parties differ or value of the task is low. For example, BH told of being required to use a computer program that extracts and faxes unverified data to nonacute locations instead of verbally reporting data and negotiating a compromise between trustworthy providers. JG related a conflict with others in introducing a new simple task to a hospital clinic hierarchy silo group based on organizational priorities. These examples of task- relationship events creating conflict hold meaning to the participants as effective (vs. outmoded) advocates and proactive (vs. powerless) employees.
In addition, task-relationship conflicts emerged in interviews when participants talked of combining fact-finding tasks and necessary communications regarding
• complicated, un-reimbursable patient issues that prevent timely discharge,
• clinically based denial of payment that required extra steps for the RN-CCM,
• limited electronic medical record (EMR) templates in an intentionally limited
and rigid computerized program,
• succinct and accurate communications involving inconsistent paging and
telephone technology or physical movement to locate physicians,
• dissemination or collection of changeable clinical information to providers
and families for transition-of-care planning, 171
• keeping vested groups informed, and
• accommodation of unexpected consequences and delays caused by of clinical
evaluation perceived by the hierarchy of powerful medical teams as prudent to
perform prior to discharge regardless of prior authorization.
In sum, tasks communicating data have meaning because they are required duties, although these events have little value of professional advocacy. Caseload and acuity also affect the potential conflict of communication tasking because of the volume of tasks that are repeated for each assigned patient every day.
Project participants described examples of task-relational conflict arising from a) interdisciplinary collaboration, b) hierarchical power gradients, c) competency of others, and d) inaccurate documentation that affected discharge efficiency. MJ described a conflict involving interdisciplinary collaboration.
You have to deal with the multidisciplinary team that even though we are all there
for the purpose of managing and taking care of that patient, everyone is not
always on the same page as to what’s going to happen. So, I think the case
manager has a tough job because you are advocating for the patient, not just for
one stakeholder but a bunch of them, all the...and everybody (sigh) has a different
agenda, hm, so you have to try and connect them all and help everybody to see
exactly what the patient wants or what the patient is looking for.…It’s frustrating
sometimes, it can be very frustrating especially when you may not be necessarily
treated nicely when you are trying to advocate for the patient or when you say, 172
“The patient needs something,” “The patient told you” (MJ, personal
conversation, December 1, 2016).
MJ finds value in communicating among different employees. When MJ receives a lack of focus or knowledge among contributing team members, she is the designated communicator. This job is meaningful for MJ because she becomes frustrated by the experiences resulting from lack of connection and tact among contributing providers.
MJ also provides an example of conflict arising when the hierarchy affects RN-
CCM advocacy.
[Conflicts] resolve, sometimes they don’t but sometimes they resolve by just
talking it out with the different providers because we are in a teaching hospital
where we are working in, like, a tier system dealing with the intern, the resident,
the fellow, the this the that, before you get to the main person, so you try to kinda
go up the ladder and if you are finding that whole entire team is not listening, then
I go directly, I send an email to the attending. I say, “This is the issue and this is
the barrier and this is what needs to happen before this patient will be able to get
out of here.” And usually they will respond. Most of the time the tiers below do
not want to bother their boss so they don’t bring anything that we are saying to
them. They think they can handle it here, but they don’t really have the
understanding sometimes, so it kinda gets stuck and we have to skip them and go
directly to the attending. And then if that doesn’t happen the system is supposed
to have in place checks and balances at top level that you can go to and hopefully 173
they go to them and have the discussion. It sometimes happens, sometimes it
doesn’t, um hm…[the system] has a backup plan.
[The discussion] is driven by the case manager. So, if something is not
happening, because say the doctor has dug his heels in and says, “Nope, that’s not
going to be how it is, I don’t care what the rules say or what the policy says,” then
we are supposed to escalate it, and then explain to the person at that level, that
will in turn have a conversation with them and …
MM: So, you have a hierarchy you have to deal with.
MJ: Yeah, yup. Yeah…there’s nothing you can do [when] the system that
is placed to check it doesn’t check it, what can you do (MJ, personal
communication, December 1, 2016).
MJ describes a hierarchy in which the case manager has limited authority directing intern resident or attending physicians to comply with regulations. As an employee, she is delegated to facilitate resolution, which involves contributions to medical team care planning, but she lacks the authority to challenge the medical team directly. She is obligated to ascend the chain of command with no expectation that her efforts will yield the desired outcome. Performing this task-relationship is not directly patient centered and the responses she perceives as “not nice” have a negative meaning for advocacy. This task-relationship is meaningful only because she values being a trustworthy employee. MJ mentally disengages in these time-consuming task-relationship events after completing her duties as an employee. The duty to pursue staff who have competing priorities results in using precious time ineffectively. This task-relationship 174 competes for MJ’s attention to duties that she perceives to hold meaning such as advocating and problem-solving.
The third example of task-relational conflict involved BH’s discovery of inaccurate or outdated information that requires correction so appropriate plans will be approved by others who are reading computer-generated screens:
A lot of the SNF screeners have been laid off and the decisions are being made at
corporate offices now based on information that has been faxed. And the
information may just say....All right, Friday patient got a denial from a facility
because the patient is on a 1-to-1 sitter. Patient has been off the 1-to-1 sitter since
11-29 [a week]. But the notes are cut, pasted, and carried forward.…It’s not based
on looking at the patient. It’s not based with talking with anyone taking care of
the patient, it’s not based on talking to the patient or caregiver. It’s based on an
electronic medical record that may or may not be accurate (BH, personal
communication, December 3, 2016).
Another sample of task-relational conflict theme comes from JG, who described an autonomous task as she starts counting while glancing at a census report:
Thirty, 90…I probably look at 120 people in the report a week. I would think
something like that, and then from there maybe I’ll have maybe eight to ten I’ll
have to get into care. I’ll either call the patient and ask “What are you doing? Do
you need resources?” and then I’ll try to refer them to any resources in the
community, like WIC, Every Child Succeeds, all those different resources (JG,
personal communication, November 18, 2016). 175
After finding patients on the census report, JG calls the patient, gathers unreported details, and determines a course of action. Later, JG discussed the relational silos she faces when attempting to advocate for her identified population being tracked in clinics:
I can’t say that the institution moves very quickly. Um...too many different, I
think, leaders over (pause)…like maternity, we have four different areas and they
all have different people they report to so you can’t talk to so-and-so because they
have a different boss.…OK, so this gets into when, you know, you can see the
benefit of something happening and the institution can’t (ends mid-sentence). I
would like to talk to the clinic but I can’t so my hands are tied. So, I can nicely
say, “Can you look into this patient?” …Like I just sent this today, to this clinic
patient but they have a different area, so I can’t tell them how to do their job. I can
just say, “She’s coming.” ‘Cause, we work in that area, we are visitors in that area
to work in. So, we see all the people that are in the clinic but we don’t work for
the clinic. Um, we send our preterm case managers there, our diabetic case
managers, they go to the high-risk clinic every week but don’t work in the clinic
so it’s a little touchy…
MM: Disconnecting, sort of like turfy.
JG: Yeah. Sad. And I don’t know, I just keep thinking every day, can we
break down some of those silos and work together, so... (JG, personal
communication, November 18, 2016).
JG identifies obstacles to collaborating on behalf of patients. Because she values and finds meaning in advocating through process improvements, she feels frustration, a 176 sign of conflict between desired outcome and, for whatever reason, resistance from other siloed groups within the hospital.
CM experienced task-relational conflicts created by the perception of others’ general lack of competence or motivation to change:
Not everything is always accurate, unfortunately, because I do find a lot of people
guess. And they fill things out based on what they are reading rather than actually
talking to the patient. So that is one thing I find very important for case managers
to do, to be at the bedside, to verify themselves what their address is, where they
are going on discharge. Some people don’t even do that. That is a big deal.
Especially as a float and I go up there and they say, “Everything is ready for
discharge,” and I go in there and say “OK, you are going to this address.” And
they say, “Oh no, I’m going to my daughter’s.” Do you know what I mean? So,
people haven’t followed through on all the things we need to do to coordinate that
whole plan of care. And it’s sad. If my name is on it I have to make sure that I did
it. The problem is I know some of the people I can trust because I’m all through
the hospital and they know the people who have the same plan that I do each day.
There are some people I know and you can tell, just by their documentation they
haven’t met that patient. Sad. So, I start all over. I start all over because I want to
make sure that patient has everything they need. So, I always go in and verify
everything before I’m discharging everyone. Make sure I know where they are
going, make sure I know that they want these services or need services if they
haven’t been set up. And I do that. And I also when I do my assignment every 177
day.…This is one thing I forgot to mention earlier, with our Interqual, our
utilization work. I never can trust that it’s been done for a patient whose been
there 10 days. For example, so I always look up what the patient’s insurance is.
And a lot of times it might be a Medicare product. We are doing the
documentation on all the Medicare products. I’m making this up, it could be a
[Scripps] insurance but it’s a Medicare Preferred and that is someone who has to
have utilization done. Just yesterday, I had one who had been there 18 days and it
hadn’t been done. So, I’m going back and checking everybody making sure
everything is accurate for that discharge and that all that work has been done.
Does that make sense?
MM: So, you value making sure the documentation is in the system so that
bills get paid because that is what hospitals expect.
CM: Exactly (CM, personal communication, December 1, 2016).
These examples of work-based relation-task conflict came from RN-CCMs in acute-care settings. For telephonic nurses, the task-relational activity is less immediate and requires persistent reinforcement with caregivers and others who perceive turf issues when confronted by the RN-CCM. Two examples of this conflict theme start with MC:
I think case management is kind of evolving, isn’t it? There are different aspects
to it, especially with all those Medicaid changes…it’s that collaboration I was
talking about and the integration we are trying to do with the hospital care
managers. I am an employee of [Sunshine Hospital], yes, but we are doing the
case management for these two particular insurance plans so it’s difficult 178
sometimes not to duplicate work(?) that the hospital primary care team are doing,
or the specialty care teams are doing. And sometimes there are territorial kinds of
things kind of going on there too, where they are protective of their turf, sort of,
do you know what I mean? … So, it’s a little dicey just kind of navigating that
and not duplicating work. I don’t want to duplicate what they are doing and vice
versa.
MM: And you want to know if you are duplicating before you duplicate
it...
MC: Exactly, yeah, of course! And it’s all a matter of
communication…and some, as I say, are a little more easier to work with than
others and it’s also because.…I get it as a barrier because they exclusively use one
system for documentation, and they don’t see here and of the two I can see the
[computer program template screen] and they can’t see here and know what I am
doing. So, it’s kind of a barrier to that integration and trying not to duplicate (MC,
personal communication, November 18, 2016).
These conflicts of task-relations are pervasive. Fortunately, not all conflicts of this type are detrimental in a changing system, as KF offers:
With the initiation of the [computer template system], that was a huge transition. I
was a super-user with that and that was an eye opener. A super user, oh God.
[We] test and we train staff. There were about six to eight of us. It went very well,
considering the differences in staff, like the older people and the younger techy 179
people on staff. I think so far so good (KF, personal communication, December 1,
2016).
KF embraced the task of educating peers on the computer system functions. This example suggests that tasks alone are not conflicts. Accomplishing tasks is a duty as a trustworthy employee. Performing tasks per se do not represent the complex ethical virtues of non-maleficence, benevolence, justice, or patient autonomy, other than as the means to the end of facilitating efficient documentation, care needs, or reimbursement requirements. The contribution that tasks make gives them value and meaning, and for that reason they may contribute to any type of conflict involving some kind of interdependent relationship.
Conflicts of task-relation develop within the collaboration processes between RN-
CCMs and others who have assigned different meaning to the problem at hand. The examples in this section show RN-CCMs as trustworthy employees holding value, but having little ethical meaning as advocates when performing task-relation required to meet regulatory metrics created by others’ expectations of rightness of care. One caveat: the meaning and value RN-CCMs give to the conflict of relation-tasks is not always clear to the observer and may be multileveled and deeply personal. Conflict of tasks and relations is a topic of importance to health care industry. Less definable than task-relationship conflicts but of higher import is the last category, conflict of caring.
Conflict of Caring: Scope, Advocacy, Attributes, Moral Distress, and Self-Care
The last emerging theme, labeled conflict of caring, identifies the risk of moral distress resulting from unprocessed conflicts of caring and concludes with expressed 180 methods of self-care that suggest approaches to mitigate adverse outcomes from such conflicts. This theme is associated with the highest value and meaning-making for RN-
CCMs because it includes the processes of complex problem-solving, a unique skill set of the RN-CCM. Consequently, these scenarios also present a significant risk of moral distress. This conflict theme is defined based on participant descriptions, the social implications of those descriptions, and supporting literature. The conflict of caring theme emerged from descriptions of lived experiences of being an advocate in certain high- stakes situations. Conflicts of caring may or may not involve change and task-relation conflicts, require extensive time to accomplish, or mandate confrontation. However, conflict of caring demonstrates some kind of extraordinary effort to mitigate obstacles to patient care. This lived experience of the phenomena of conflict possesses a different quality of meaning for RN-CCMs than conflict of change or task-relationship. Most significantly, the conflict of caring events contains meaningful advocacy for each case manager defined by their scope of practice. “The role of the advocate takes many forms but one is to speak up when one is concerned for the safety or well-being of a patient”
(Shannon, 2016, p. s43). Therefore, effective advocacy during conflict of caring requires
RN-CCMs’ competence in ethical principles of conduct; complex, multilayered clinical knowledge; and communication skills to educate effectively using empathy and emotional intelligence. This conflict theme requires simultaneous cognitive, emotional, and compassionate empathy and emotional intelligence and thus describes the advocacy unique to RN-CCMs. 181
Advocacy. Advocacy skills are required to perform meaningful interventions mitigating patient-centered problems. In chapter 2, values of caring appear to be based on the ethical virtues of beneficence, justice, and autonomy as defined throughout
Beauchamp and Childress (2013). The meaning and value attached to ethical virtues empowers advocacy skills. Advocacy to resolve conflicts of caring comes from perceiving the benefit to the patient of intervening and the ability to contribute effectively. Although RN-CCMs may not use these terms when defining conflict experiences, the efforts they make are based on the value they give to helping others. The phenomena of a conflict of caring experience is conveyed as deeply meaningful and therefore are valued experiences of performing what can often be emotionally charged problem-solving on the job. Effective advocacy contributes meaningful collaboration in problem-solving any conflict of care.
Qualities of advocacy for hospital bedside nurses’ lived experience of power found that nurses believe power develops through the acquisition of knowledge, experience, and self-confidence (Fackler, Chambers, & Bourbonniere, 2015, p. 267).
Likewise, research on EI revealed that nurses with more than six years of experience had higher levels of emotional competency and concluded that emotional intelligence processes are central to nursing growth and development and to professional competency
(Heffernan, Griffin, McNulty, & Fitzpatrick, 2010, p. 368). Nursing students’ conflict management styles of integrating and compromising have been found to correlate with higher EI scores (Chan, Sit, & Lau, 2013). Motivation to advocate in conflicts of caring is created by RN-CCM participants’ perceived power to inform, competency of clinical 182 knowledge, and empathy for what the patient is experiencing. However, the RN-CCM has a unique and skilled role in problem-solving different from any of the researched roles.
The RN-CCM’s advocacy differs from those of other front-line caregivers as evidenced by the unique experiences reported in these interviews. RN-CCMs possess years of hands-on patient care, providing experience in how and when to exert their knowledge and behavioral skills in pursuing an intervention. Also, advocacy includes providing patient education. In conflict of care, the patient benefits from the RN-CCM’s intervention as an advocate who possesses experience, critical thinking skills, and advanced communication skills. The RN-CCMs interviewed gave value and meaning to mitigating perceived conflicts of caring affecting patient autonomy.
Attributes. Contributing RN-CCM attributes are empathic maturity and emotionally intelligence. The narrative excerpts aligned with empathic maturity as defined by Olsen (2001). Empathic maturity levels observed in the examples below are based on how RN-CCMs identify meaning in a patient’s situation and is significant in how the phenomena of conflict of caring is experienced. The conflict of caring emerges when an RN-CCM makes a conscious decision to pursue advocacy in the context of changing or decreasing resources, restricted authority, variable disinterested hierarchies, and a patient’s or personal caregiver’s level of understanding and motivation. Each participant perceived education, compromise, and supportive interactions to integrate priorities as venues for advocacy. 183
The conditions creating conflict of caring are complex. The following excerpts demonstrate how RN-CCM give meaning to the conflict of caring including advocating by meeting others where they are and educating them on options. Conflict is mitigated through empathic maturity, EI, and conflict management skills when encountering the disparate group norms of separate medical teams and medical practice protocols. The interactions described below hold meaning and value primarily as a patient advocate.
MC, the pediatric RN-CCM, advocates for safe and creative resource utilization.
Problem-solving involves education, communication, and empathic maturity, suggesting an empathic maturity described by Olsen’s level III because she communicates to professional peers without passing judgment on the patient and understands how the patient feels overwhelmed and cannot follow the specialist’s instructions for life- sustaining feedings:
We do reinforce teaching anything that they do in the hospital and primary care
sites, the specialty care sites. I can see that in [our computer program]. I can see
how “They want you to do the feeding schedule, and this is what the doctor said
that in order and step by step, and the medication. Over the next eight weeks they
want to go up on this medication and that’s what the prescription says and tell me
how you understand this.” So, in that way, yes, I do think about the complexity of
what I’m trying to teach somebody to understand so it’s like being an interpreter,
especially when it’s a different language. But, yeah, they can be complex. So, so
we do, ’cause I can see in [computer programming software] that they are
reinforcing that teaching that they understand…and sometimes we’ll find out 184
when we call them that they are not doing it correctly or and then we explain to
them, and then we also contact the provider, and say, “Hey we just talked to this
mom, and just letting you know she has not been giving this feeding properly, and
this medication properly” or “You sent this prescription to her two weeks ago but
she is not able to pick it up yet so we need a prior authorization” and they may not
be aware of it. [The clinic] gave her a prescription 2 weeks ago and “Bye, we’ll
see you in three months.”
MM: So, they don’t understand the all the things, the obstacles to getting
that prescription filled that they just give...the prescription to be filled.
MC: Exactly, so that’s, if a family member never calls them and they let
just the prescription sit there (MC, personal communication, November 18, 2016).
MC discovers a potentially catastrophic gap between clinic instructions and a mother’s follow-through. The conflict of caring emerges because the child’s treatment is incorrect because of a lack of clarity. As an advocate, MC empathizes with the mother’s experience at the clinic, assesses the situation without judgement based on her clinical knowledge, and, as an advocate, intervenes skillfully to meet the mother at her level of understanding.
The second example is a brief reflection showing empathic level III awareness, emotional intelligence in temperance about others’ actions and staffing opinions, meaningful alternative views to social norms that dehumanize other, and conflict management skills. KF reflects on repeat drug addicts being readmitted for medical 185 complications. KF perceives the value of advocacy by meeting the patient in a shared experience of human suffering to find a way to connect to encourage insight:
Just from the floating experience there are different times the person’s
presentation into the hospital, like what they came in with and maybe either their
own past history, whether it’s current or remote impacts, how the team is going to
somewhat treat that patient and sometimes how they are going to extend
themselves for that patient. Like there will be cases, you know, we’ve all had
them, the IV drug abuser, Narcan a couple of times, they come with endocarditis.
And some people are more, uh, have more of an emotional detachment to people
like that because they feel sorry for them or they just, they are very empathetic
toward that situation and other people are just well, “If you aren’t shooting
yourself up this wouldn’t have happened to you.” So, you see that every once in a
while, depending on the providers. I think a lot of times that just implies, “Well,
it’s kind of your own fault” kind of thing. I don’t take that as an empathetic
statement. I mean I think it’s, like anybody, you smoke, you have weight issues,
you maybe drink a little bit too much maybe. Maybe you know somebody’s
who’s not on target with their meds, there are certainly ways…It’s like
motivational interviewing. Look at that whole thing. You are in there like, “Oh
OK, I haven’t seen lost one pound since I saw you 3 months ago.” And you are
like, “OK, what are your challenges or what would make things easier.” Like you
don’t see a lot of that here, at all, any kind of motivational processes.
MM: Trying to meet the patient where they are…. 186
KF: Yeah.
MM: …Here’s where the organizational person is and here’s where the
patient is (KF, personal communication, December 1, 2016).
In reality, the ethical conflict embedded here is not fixable. KC finds value for this patient in her personal view of human suffering. The meaning KF implies in this description refers to the other’s offering a meaning to life by seeing others as ourselves in different circumstances. KF’s view has meaning and value in facilitating care planning for someone who presents a conflict for the system: what appears to be voluntary self- destructive behavior challenges the caregiver’s meaning of beneficence. Behaviors are judged as self-inflicted and ignorant; KF finds meaning in opposing the standard response. The conflict of caring in this situation also has meaning in the way KF’s values oppose the stated views of co-workers.
The third example is an acute event KF described when treatment options are exhausted and the conversation about end of life is perceived as the most compassionate choice. Here KF, as the transient float RN-CCM, acts as an advocate during the most poignant transition in life which is death and resulting separation. In this description, empathic maturity and perception that a lack of education about a terminal stage of life can lead to confusion and create a moral dilemma for the family. The RN-CCM describes her personally draining response in having to correct the emotionally fragile course of care. The futility of care scenario illustrates a common risk for moral distress and residue
(Moffat, 2014). 187
It was about a week or two ago I sent home, it was a weekend, and it was a young
wife, she was like 47 with like 2 cancers. They were treating her and treating her
and finally they were like, “OK she is going home with hospice.” I went to see her
on Sunday. The attending said to me, “No, Kelly, this isn’t hospice” [and I said]
“Why wouldn’t it be?” [The attending says], “She wants...to be able to get blood
transfusions.” So, I said, “OK, so has anybody talked to her about what would
happen if she didn’t get blood?” They were like “No.” Then so I said, “So I’ll go
in there and talk with the patient about these things. And blood draws too.” Then
the husband was like, “Well, how are we going to know if things are getting better
or worse?” I said, “Well, based on the nurse’s assessment and your input.” And he
was like, “Well, OK.” Then the attending got nervous and called the primary
oncology, it was like, “Absolutely this is hospice. She is not going to get better.”
And she went home and she passed away a couple of days later. So, you just leave
there, and it’s just very sad when you see to that extent how they treat people and
then they go home to hospice and then they pass away....It’s very saturating,
extremely saturating. I tend to take a lot home with me (KF, personal
communication, December 1, 2016).
The fourth example of conflicts of caring involves advocacy through education in the outpatient setting. HR respectfully and consistently offered valuable information to promote dignity, a meaning-making value of the RN-CCM role. Empathic maturity emerged in perceiving obstacles arising from a lack of confidence in the family care 188 provider, the lack of patient competency, and the physician’s view that even if dialysis continues, the outcome is futile.
I remember being in that room with the social worker, the doctor, and the
caregiver his wife, really his ex-wife, it’s all he’s got right now and him. And he
is total dementia. He’s in end of life, he’s treated at the infectious disease clinic,
and right now he is end stage renal and he is not making a difference with the
dialysis. We’ve said there is going to become a time where the wife has to make
that hard decision how much longer does she want him on the dialysis because so
weak, confused. She doesn’t want to allow home care services and you know,
that’s a tough call right there. The doctor said, “One day you are going to have to
decide how much longer do you want him to be on that dialysis,” but being in that
room. The patient can’t make that decision, the wife is the health care proxy. She
has to make all these decisions and she herself is burned out (KF, personal
communication, December 1, 2016).
In the example above, HR collaborates with the care provider and vendors to problem solve—not promoting or confronting the physician’s input—to provide minimal and short-term intervention knowing that the plan will require revisions.
Conflict of care includes experiences arising from perceptions that all is not beneficent, nonmaleficent, nonjudgmental, or patient-focused in health care. The conflict is not remedied by changing systems, but by interceding case-by-case in meaningful advocacy. Despite effective conflict management skills, empowerment based on reputation, and years of experience, RN-CCMs will perceive futility in how health-care 189 systems function. The following two excerpts illustrate examples of personal values conflicting with organizational and other priorities. These observations reflect RN-
CCMs’ insights about distributive justice; the conflict of caring in these comments is not about intervention as much as compassion in what patients experience.
Distributive justice and distribution of resources [being equal]. Why are we
transplanting people three and four times? Where is the decision-making on that,
opportunists? Money. If you aren’t getting paid you would not be doing it.
MM: And what does that say about our values?
BH: Money, I don’t have the answers, I’m just throwing it out there. We
have an acute guy, we are trying to get him down to.…[H]e needs a liver
transplant. He’s thirty-four, has two kids, four and two, and Blue Cross won’t pay
for his way down because they can do a liver transplant in Massachusetts but the
waiting list is three years. (Pause)
MM: So, it’s a way of excluding him.
BH: If you go down to Mayo they can do it immediately, but they won’t
pay for the air ambulance down. So, I mean…
MM: Do you ever feel like there might be a different set of priorities?
(BH, personal communication, December 3, 2016).
KH reflects on treatments plans which she has no direct power to divert but which affect her because the motivations appear to conflict with her view of compassionate care. 190
Oh yeah, research. Especially like Blakely Cancer Hospital and stuff like that.
And surgeries too. Like where you see it over here, today there was a ninety-year-
old and they want to do a valve replacement. I’m like…eighty-five with dementia
going, they want to have a family meeting about doing a CABG. I’m like, “Oh my
God, the guy has dementia.… (KF, personal communication, December 1, 2016).
In these excerpts, conflict of care is perceived based on experience of the health- care system’s priorities and the motivations behind those priorities. The ethical challenges of distributive justice articulated are compelling when experienced by a person who is observing and is powerless to realign the inequities. BH continues to describe intervening to help patients when the system does not always advocate in the same way. Successful advocacy experiences are critical to sustain meaning for BH in his profession. He articulates conflict of care and his resilience in accommodating the realities of health-care systems that appear to him to demote compassionate patient advocacy.
Figure 5.1 organizes the four central ethical principles in a circle with subsets of the emergent themes of conflicts as well as specific examples from narratives. This figure illustrates the relationship between ethical principles, conflicts, and lived experiences experienced in RN-CCMs’ daily routines.
191
Figure 5.1. Relationship of principles, conflicts of change, task-relationship, and caring.
Figure 5.1 represents the emergent dynamic of actual problem-solving events manifesting as conflict of change, conflict of task relationship, and conflict of caring processes. Table 5.2 establishes the same conflict themes, principles, actions, and examples emerging from interviews. 192
Table 5.2.
Phenomena of Conflict, Ethical Principle, Action, and Examples
Phenomena of Conflict
Change Task-relations Caring*
Ethical Autonomy: Justice: What is Non-maleficence, principle Providing choice, deserved and equal beneficence (and giving liberty and agency in (political rights for autonomy for patient meaning to performing duties hospital, patient, rights and distributive conflict (RN-CCM as providers paying for justice in allocating employee) health care, CCM services) time/effort to meet goal Action- Trustworthiness in Collaboration with Ability to assess and interaction and meeting others’ others on basic tasks identify conflicts context of expectations to achieve optimum using compassion and ethical outcome among kindness. Requires principle competing priorities competence in empathic maturity, emotional intelligence, and seasoned critical thinking for problem- solving Example Practical dilemmas Practical dilemmas Advocacy in volunteered by vacant positions, embedded in tasks identifying & solving participants changing requiring problems. Ex: HR management, communicating data to meeting patients redundancy of meet goals. CM timely where they are, KF & duties, changing data entry, BH MJ intervention with protocols. Everyone computer accuracy vs. terminal patients. had an example JG, face to face; MJ vs. CM, BH MD Note. Potential for risks of moral and ethical distress and long-term impact if dissonance
(conflict) experienced due to knowledge, action and perception of adverse outcome.
*Most complex competency of RN-CCM.
193
The phenomena of conflict themes are associated with ethical principles presented in chapter 2, while moral action associated with that principle and specific examples are taken from RN-CCM interviews. For example, caring, the most complex conflict for RN-
CCM, represents all ethical conflicts discussed in chapter two. These actions are pervasive in RN-CCMs’ daily duties and demonstrate the complex critical-thinking skills that inform every discussion about patient care. Figure 5.2 illustrates contributing factors to decision-making in the health care context. Figures 5.2 and 5.3 together dissect external variables and internal attributes observed by RN-CCM narratives of lived experiences.
Figure 5.2. Problem-solving contributing factors in health-care context. 194
Figure 5.3. RN-CCM matured attributes used when collaborating and problem-solving.
Note. Large circle represents individual RN-CCM participant.
Moral distress: A risk to RN-CCMs experiencing conflicts of care. The risk of moral distress increases if conditions promoting advocacy cannot change or antidotes offered through self-care efforts do not reinforce a positive self-image. The risk of moral distress is present in ethical dilemmas emerging from conflicts of caring and are uniquely profound in the RN-CCMs scope of practice. KF indicated signs of this when she referred to taking some of her work experiences home at the end of the day.
All conflict themes represent potential accumulating psychic burdens to the RN-
CCM. Moral distress has been identified as a consequence of experiencing unresolved conflicts that have meaning and value to RN-CCMs. Three common factors influence how moral distress is experienced as a product of conflicts are “the context of the situation matters; the value of coming together as a team; and looking for outside direction” (Peter & Liaschenko, 2013, p. 294). Each RN-CCM valued advocacy in 195 meaningful situations such as end of life or preventing potential failed outpatient interventions. Connection with peers or manager was valued most by those employed in specific positions: MC, JG, and HR identified positive meaning with the professional support systems available to them. The float nurses valued permanent team support less and placed more value on their adaptability within many clinical teams in the acute-care setting. So, these seasoned RN-CCM have found meaning and value that may mitigate the impact of moral distress based on lack of valued work situations and connections to team.
Peter and Liaschenko’s (2013) third element to mitigate the influence of moral distress is outside direction, which includes self-care. Self-care can include meaningful activities done voluntarily on the job to replenish personal equanimity for return to workplace duties (Steinwedel, 2015, p. 75). For example, HR reported climbing stairs after stressful encounters, MJ engaged in measured contact with challenging personalities, and CM kept time boundaries in her workday schedule to avoid lapses in family obligations.
RN-CCMs’ reported lived experiences reinforce research on conflict causes and qualities, although none of the literature from chapter 2 profiled the RN-CCM specifically. The next section reports on self-care activities perceived as adding value and meaning to life and work experiences.
Case Management certification as self-care. Seeking case management certification was consistently meaningful as a vehicle for networking and for assimilating current health-care trends into practice through professional continuing education 196 required to maintain certification. Participants overwhelmingly valued as self-care, self- improvement, and an enhancement to one’s resume when seeking new employment.
Certification was not seen as directly influencing current status in hierarchy or working relationships or obstetric specialty.
CM perceived the exam to hold value in establishing advanced knowledge and expertise.
If I was hiring someone in my former management position, if I was hiring
someone, I would look for the CCM over the other one because it shows a far
broader experience in taking that exam to showing what your knowledge is (CM,
personal communication, December 3, 2016).
KF similarly identified expertise as well as keeping current on trends and networking benefits:
I think what is really does is lay down a platform, a foundation for practice.
There’s an organization for case managers with the development of standards of
practice and things like that. Certainly, case management is a nursing specialty
and a lot of people don’t realize that (laughing). I think it keeps you more in tune
to the changes in health-care area. You know you get these email blasts and you
used to get journals. You know standards and evidence-based practice in certain
areas in terms of having best managed patients and things like that. I think that
helps. They have the conference here every year, not many people go from here
(KF, personal communication, December 1, 2016). 197
HB recognized professional networking across the states and noted that even case managers work in silos, so conferences enhance communications and implied the advantages of establishing professional status in large numbers.
If I hadn’t become certified I don’t think I could do this job. I think the best thing
I ever did was my peers where I was working. I was a telephonic intake case
manager at a home infusion company. I know all the nurses that I report to and
got the referrals from said, “Helen, we’re getting certified.” I said, “Oh, what’s
this, tell me about your certification.” Then I found out I met the criteria. I had
everything you needed. I sat for the exam. I feel you have to have that level of
expertise. You need to go to your conferences in your local area where you live,
in the state you live in. You need to go to the conferences nationally to know
what’s going on at the national level. We need to know what’s impacting case
managers across the nation because we are each other’s sounding board. We
know how to access resources. I learned something new every time I go to a local
case management conference. Now I just presented November 7th at the Geriatric
Nurse Case Managers of New England. You want to know what our presentation
was? Learning how to collaborate with case managers in all settings and the
geriatric certified case managers. Many of us work in silos. We sit here and work
like this parallel, but people are not communicating. That was my second year. I
did this two years ago. We need to work on how to work together. You know it’s
one of those thing s you’ve got to do. You have to. I know what’s out there (BH,
personal communication, December 3, 2016). 198
JG took the exam to comply with her manager’s recommendation. She found the exam was clinical, not relevant to her specialty, but acknowledged it had advantages in establishing competence if applying for another job.
I guess the reason we did that when I was a care coordinator, the old manager
wanted everybody to take certification and she wanted all the care coordinators to
be certified so we pretty much are, I think. Everybody got certified; a couple of
the older ones are not. And I think it’s a good thing, if I needed to go somewhere
else it would probably with my experience add to my benefit. Um, I am going into
the meeting with, “OK when I took the case management test, there’s nothing
about OB in it at all. Nothing.” So, it was beyond our learning curve and we are
all like “Whoa!” but it was very interesting. Things I would never learn which I
was supposed to so, I enjoy learning so thought that was very interesting.
MM: Did it impact your job at all.? Affect your status?
JG: Noooo. But I think, I mean the way I look at things, I think of, yeah
(JG, personal communication, November 18, 2016).
Self-care activities give meaning depending on personal values and sense of purpose. Similarly, these nurses valued certification as a form of connection to peers and as a way to keep current on health-care topics; CCM requires accumulating continuing education credits for relicensure. Self-care is an antidote to the ubiquitous phenomena of conflict; certification gives a sense of meaning and professional recognition of one’s successful career as an RN-CCM. The significance of self-care to this inquiry concerns value and meaning given to activities sustaining personal self-worth. This is useful in 199 creating a program intended to mentor nurses on common conflict management events in the work environment using sustainable self-care activities.
Summary of Emergent Themes
Although the phenomena of conflict are not avoidable, certain themes of conflict require further research to determine the effectiveness of cognitive training, didactic education, and mentoring. For this project, prevailing conflict phenomena emerged in three themes labeled conflict of change, conflict of task-relations, and conflict of caring.
Conflict of change is related to RN-CCMs’ effectiveness and essential administrative support. Conflicts of task-relations are expressed as limited flexibility managing time and overlapping demands. Social morals and virtues informing ethical codes of conduct contribute to perception of task-relations and caring. Codes implicitly measure performance in general and are most meaningful and valued when advocating, collaborating, and educating. Standards of ethical conduct and expectations of collaboration also created phenomena of conflict.
This conflict theme for the RN-CCM contained unique advocacy and problem- solving. In these interviews, ethical principles guide advocacy and therefore reflect
Beauchamp’s and Childress’ (2013) structure of biomedical ethics. Effective advocacy also requires empathy and emotional intelligence combined with experience and power to problem-solve as a collaboration with multiple priorities. Therefore, attributes of empathic maturity are essential for RN-CCMs. Olsen’s empathic maturity is supported by the descriptions of patient interactions during critical moments, such as KF had in the acute-care setting and in the conversations MC described with non-acute RN-CCMs 200 when evaluating the effectiveness of lay caregivers. If the phenomena of conflict lack value or meaning or both, the risk of moral distress increases because of the perceived lack of power to mitigate ethical and practical dilemmas created by conflict. Emergent conflict categories overlap in an RN-CCM’s daily duties, creating an aggregate of compelling experiences and meaning. Identifying successful strategies to address dissonant lived experience and meaning-making associated with certain conflict themes might enhance advocacy and retention of skilled staff.
Discussion and Implications
RN-CCMs’ lived experiences have not received sufficient attention in nursing research, yet the job supplies critical links between patients and health-care providers.
Empathic maturity and emotional intelligence evolve during exposure to ethical and practical conflicts. Olsen’s structure of empathy and Goleman’s emotional and social intelligence theories give a framework for RN-CCM attributes that give them the capacity to face both unresolvable and insufficient solutions. This research has contributed knowledge based on lived experiences in managing routine conflicts according to codes of conduct and using personal attributes. The remainder of this chapter integrates these elements and addresses how the research addresses the initial research questions.
Figure 2.1 is refined as Figure 5.4 to illustrate the global interactions in which participating RN-CCMs problem-solve and collaborate and from which themes of conflict exists. Social norms of ethics influence institutional, health care, and personal moral actions.
Diagram of Ethical Dynamics 201
Society Ethics : judgment, forgiveness
Healthcare ethics: focused on financial management of population, hospital sub-groups, insurance, outside providers
Patient Centered Advocacy: influenced by empathy
Case Manager Self: Ethical Dilemmas-> duty, ethics, empathy Moral Distress Figure 5.4. Ethical dynamics of Figure 2.1 refined.
Emergent findings of conflict explored in chapter 5 can be assigned to colored circles. The red circle contains the social principles of governance, the meaning-making by which society interacts, and from which ethical actions are established. The blue circle represents bioethical principles established in health care. Specifically, conflict of change and task-relationships are relevant in the context of the health care industry. The purple circle is the RN-CCM, who applies personal attributes identified in Figure 5.3 when choosing morally ethical actions. The green circle contains patient-centered advocacy processes. The conflict of caring for the RN-CCM emerges when advocacy is obstructed by conflicting ethical actions of various health care providers. The RN-CCM’s advocacy role is influenced by the attributes of Figure 5.3. The yellow area is within all circles and contains the risks of moral distress. No one variable or experience is isolated from the context of health care and society at large. Advocacy, however, is an essential moral action for the RN-CCM when abiding by codes of ethical conduct. 202
In health care, advocacy includes anticipating and identifying obstacles that create delays and collaborating to meet expectations within one’s scope of authority. These participating RN-CCMs advocate every day by educating patients, physicians, and providers. Effective education includes seamless communication to various levels of intellect and knowledge to change behaviors or outcomes. RN-CCMs value their specific roles in unique ways depending on their attributes and personal interests. At worst, RN-
CCM jobs are becoming more restricted in scope of authority to initiate individualized interventions because of financial constraints surrounding insurance and government restrictions on reimbursement. The RN-CCM has become more of a monitor for high-risk outpatient populations and a conduit for data collection being transmitted through check boxes on computer screens, without the option to communicate social issues that impact care. The role of collaborator is being hijacked by protocols, data entry tasks, and restricted interventions. Yet the role is still essential in providing cost-effective and adequate services.
Over time these RN-CCMs have identified ethical dilemmas in everyday work events. They observe which patients are approved for what care, the lack of attention to the impact of futile care, the use of deficient network providers or no providers when non-contracted providers would be appropriate, lateral violence when changes in protocol are attempted, and dismissal of the complexity of navigating poverty and disabilities. The list is endless and inquiry on how these problems are absorbed in health-care networks is a story of compassion and perseverance. As a longtime professional in this field, I have witnessed the compassion and perseverance of case managers. RN-CCMs are effective 203 because they have learned clinical risks and effective skills of problem-solving, of emotionally intelligent responses, and of self-care defined as knowing how and when intervention is possible for an improved outcome.
In addition to alignment with the lived experiences, the research questions focused the open-ended interview questions to explore the meaning of RN-CCMs’ experiences within an increasingly complex health-care system. Research questions helped to reveal the experience of health care conflicts as unavoidable. For example, although congruent meanings of advocacy emerged, the way each RN-CCM manifested this role varied based on changing professional roles, work place contexts, and personal attributes. Three distinct qualities emerged to define the phenomena of conflict include a) significant impact of changes in the work place, b) the dissonance experienced when engaged in task-relationships, and c) the conflict of caring as an advocate.
Research questions one and three guided interview questions and coding of transcripts and contributed to finding the emergent themes of conflict and unique attributes of the participants. Common themes of conflict emerged when participants described different context-dependent experiences. The common emergent themes identified are conflict of change, conflict of task-relation, and conflict of caring, the last being unique to RN-CCMs in meaning-making as an advocate. The meaning and value of each identified theme emerged from how RN-CCMs perceived their roles as effective and trustworthy employees, benevolent collaborators among providers, and compassionate educators and advocates for autonomy of patient needs and preferences. In addition, information pertinent to research question two were identified in variables and 204 consistencies among the interviewees when determining ramifications of decision- making affecting patient autonomy. Question four guided information on meaningful self-care activities. Combining information to reveal the process of decision-making was facilitated by combining three approaches to interview content identifying a) the emergent conflict of caring, b) different personal attributes including insight on empathy supported by literature, and c) references to self-care activities nourishing one’s successful role in society. Researcher epoché and bracketing during interviews was essential in coding and, later, in identifying interrelationships between research questions and interview content. Examples of decision-making and the interrelationships of research questions to content follow.
Decision-making is the result of problem-solving processes and includes collaboration and clinical protocols. Each participant engaged in decision-making bound by their scope of practice within a health-care system: MC, HR, JG, and PN as outpatient
RN-CCMs had more breadth in caseloads; their interventions were less about care planning and more about how the home care plan aligned with the physician’s clinical intent. The acute-care hospital RN-CCMs assigned meaning to advocacy; the organization assigned meaning to cost containment and fast problem-solving and decision-making. For example, BH values collaborating face-to-face regardless of network affiliation; he feels disempowered by computer referrals and describes management’s pressure to contain cost as the meaning behind using only network providers. JG’s plan designed to research daily emergency room rosters to advocate for 205 interventions for high-risk early pregnancies among low-income mothers is encouraged by authorities because the outcome mitigates the cost of premature newborns.
Decision-making includes emerging themes of conflict experienced by all RN-
CCMs. This was apparent despite a variety of self-selected roles and decision-making required in various working environments. Furthermore, in describing events revealing a conflict of caring theme, each RN-CCM reveals attributes of empathic maturity in decision-making and, ultimately, the meaning-making of their roles as advocates which holds value above all obligations. The value of advocacy is evidenced by taking exceptional actions to resolve circumstances defined as conflict of caring. In summary, question two is addressed in RN-CCMs’ perceptions and the meaning assigned to various conflict experiences.
Decision-making was influenced by external work environments and also by personal attributes creating a potential for conflicts of caring. Each participant excelled in their decision-making ability because the job complimented meaning-making of their actions, their interests, and personalities. Specifically, decision-making was influenced by each RN-CCM’s empathic and emotional intelligence, clinical expertise, and reliability in operating within the assigned scope of practice. For example, HR perceives other with compassionate tolerance manifested in her steadfast attitude to support the high anxiety of her highly excitable patients. The RN-CCM’s empathy and emotional intelligence made a significant contribution to identifying the emerging conflict of caring theme. The interrelationship between empathy and conflict of caring is illustrated when MC described her personal experience with the challenges of caring for a disabled child 206 during a story expressed with respect and acceptance about interacting with parents of disabled children.
Another variation in personal attributes affecting variations of decision-making is personality, which was revealed in how they interact with others. These RN-CCMs have survived many years in their professions and display levels of tolerance for and accommodation of unsettling job variables that less resilient peers might not. For example, BH held meaning in his years of experience and professional endorsements. He felt his current discharge planner role, limited to computer communications, was demeaning to the profession. He would likely find the outpatient role less satisfying.
Likewise, MC or PN would likely experience the complex details of tertiary hospital discharge planning burdensome and the stress of conflicts in that setting unsustainable.
Other examples of personality influencing decision-making and conflict of caring are JG, who clearly had a proclivity to resolve system problems despite slow responses to her recommendations. Alternately, KF, CM and BH—each competent, independent, and resilient—presented attributes of adaptability suitable for float positions. “No day is the same for floats.…I’ve become a really good problem solver” (KF, personal communication, December 1, 2016). Float assignments are inconsistent and constantly challenging in a way telephonic tasks and chart research are not. Further research would be useful in determining personality types suited for certain decision-making tasks.
Finding a good fit for or adapting personal attributes to job duties, these RN-CCMs have found meaning and value in their perceived roles as a case manager professionals, improving patient outcomes when possible. In the end, researcher epoché and bracketing 207 were invaluable tools to clarify RN-CCMs’ perceptions and assign value to the collaborator role within individual contexts when facing unique conflicts. These researcher approaches allowed the RN-CCMs to express how they work using ethical codes of conduct that influence daily decision-making.
Research question four asks how decision-making changes RN-CCMs’ lives. The intent of this question was to explore positive attitudes or lifestyle choices based on the decision-making experienced in the work environment. KF said that interactions with many clinical specialties has “changed the way [she] thinks globally and big picture rather than focused on one type of patient” (KF, personal communication, December 1,
2016). This concept is also reflected in CM’s political activity; over time she has perceived the value of case management and has placed meaning on developing public policy to support case management in health-care reform. PN’s management experience, business background, and certification were factors in accepting a role in a new program to monitor chronic disease populations. These examples demonstrate unique decision- making choices giving value and meaning to further expand their contributions to society.
Implications and application of inquiry. This inquiry concerns an experienced professional caregiver who lives somewhere between bedside nurse and middle management in network hierarchy. The RN-CCMs’ scopes of practice are defined by the changing priorities of their employers. Applicants for these roles are often unaware of the relentless and often dissonant expectations of family, doctors, administration and financial institution protocols, and obstacles to best options. Health-care dilemmas are contextual and perceived as conflicts based on values and personal attributes. Measuring 208
RN-CCMs’ empathic maturity and emotional intelligence may determine effective skills to mitigate ethical dilemmas that result from conflicts of caring. Additional research might investigate coping skills used in conflict management to mitigate practical dilemmas that result, for example, from changing protocols such as software systems or relation-task conflicts concerning transition of care or both. Other topics might address the perception of the benefits in coping skills in cultivating attunements to emotional intelligence and empathic maturity associated with conflicts resolution.
The implication of this inquiry is that RN-CCMs take on challenges every day, reflecting the frequently muddled labyrinth of health-care systems. More research on this role will highlight the complicated system and answer the questions: How do health-care professionals develop an understanding of ethics and conflicts? What benefit results from understanding the long-term impact of numerous ethical and practical conflicts which the
RN-CCM often witnesses without authority to change, such as distributive justice and futile or dissonant treatment plans?
This research is also relevant to the area of self-care because the meaning-making given to self-care activities is valuable in mentoring case managers on conflict management. Managing conflict includes replenishing spirit and identity. Participants assigned meaning to confidential debriefing with peers or others, short stress-reducing activities on the job, advancing education and certification, and hobbies, including physical activities.
The motivation to investigate this topic has been two-fold. Introducing a dynamic, unappreciated role in health care and understanding the lived experiences would 209 contribute to a meaningful mentoring program for new and maturing case managers. For example, if one learns to identify or enhance existing qualities of empathy and emotional intelligence and meaningful self–care activities, then meditation and mindfulness may help to identify personal integrity and refresh the meaning of advocacy and underlying ethical principles supporting self-worth. There is no time to lose, given the current pace of migrating demands in health care networks. 210
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Appendix A: IRB Documents
1. Approval letter
Project Number 16-X-47
Project Status APPROVED
Committee: Biomedical IRB
Compliance Robin Stack ([email protected])
Contact:
Primary Mary Moffat
Investigator:
Project Title: Exploring Moral Distress in Hospital Case Managers
Level of Review: EXPEDITED
The Biomedical IRB reviewed and approved by expedited review the above referenced research. The Board was able to provide expedited approval under 45 CFR
46.110(b)(1) because the research meets the applicability criteria and one or more categories of research eligible for expedited review, as indicated below.
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IRB Approved: 02/24/2016 08:21:35 AM
Expiration: 02/24/2017
Review Category: 7
Waivers: N/A
If applicable, informed consent (and HIPAA research authorization) must be obtained from subjects or their legally authorized representatives and documented prior to research involvement. In addition, FERPA, PPRA, and other authorizations must be obtained, if needed. The IRB-approved consent form and process must be used. Any changes in the research (e.g., recruitment procedures, advertisements, enrollment numbers, etc.) or informed consent process must be approved by the IRB before they are implemented (except where necessary to eliminate apparent immediate hazards to subjects).
The approval will no longer be in effect on the date listed above as the IRB expiration date. A Periodic Review application must be approved within this interval to avoid expiration of the IRB approval and cessation of all research activities. All records relating to the research (including signed consent forms) must be retained and available for audit for at least three (3) years after the research has ended. 223
It is the responsibility of all investigators and research staff to promptly report to the Office of Research Compliance / IRB any serious, unexpected and related adverse and potential unanticipated problems involving risks to subjects or others.
This approval is issued under the Ohio University OHRP Federalwide
Assurance #00000095. Please feel free to contact the Office of Research Compliance staff contact listed above with any questions or concerns.
224
First, we appreciate your time and contribution to this dissertation qualitative research project.
The focus of this study is exploring moral distress potential in case managers.
Moral distress is defined by Ann Hamric in 2012 as a “form of distress that occurs when you believe you know the ethically correct thing to do, but something or someone restricts your ability to pursue the right course of action.”
Research has shown certain bedside nursing specialties have some risk for this distress. I am investigating if case managers also have some risk for this distress based on the case manager’s unique job responsibilities.
During this interview you will be asked to answer:
1. General questions about the environment in which you work
2. Specific questions exploring the unique duties of hospital case managers
The interview will be audio recorded. You may stop the interview, decline to answer, or ask that recorder be turned off.
This interview transcribed eventually. ALL responses are anonymous. A pseudonym will be used for reporting purposes and your employer will not be identified.
You will be able to review any written material collected for accuracy and content.
If you have any questions after the interview or if you would like more information please ask.
THANK YOU, Mary Moffat Best contact: 857-234-1078 [email protected]
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Appendix B: Interview Questions
General questions: interview opening questions
Hospital genealogy chart
CFO down through VP, patient care services, team leaders, how assignments are made (by floor or service)
b. job description
Who do you see as informal leaders among management and peers
What are your scheduled hours, typical day, events, cross coverage for sick time?
(Block study) Physical setting: how many in office? Do you share electronics, space? How does this impact your work flow if at all?
Years worked, past experience, changes over time with job title, CM job duties?
Positive and negatives of the job in general.
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Have you felt compelled to intervene in a patient’s immediate condition based on nursing knowledge (e.g. finding abnormal lab reported)?
Terms (secret language) used to describe difficult situations or positive ones.
Body language? Consider non-verbal, clothing, facial expression, proximity, interpersonal distance, body movement
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Case Management Specific Questions
A
In general terms what financial obligations in care planning cause case managers conflict or agreement among the patient’s caretakers? Consider the following general categories to represent separate responsibilities: organizational vs clinical; clinical vs personal; personal vs organization?
B
Describe case management specific responsibilities requiring you to mediate and resolve conflicts? Examples of situations might include: delay due to processing of medication scripts, med reconciliation, underinsurance, special network or charity needs approval, denial of transition plans to non-acute setting, compliance, proving medical necessity for continued stay or acceptance/approval to acute rehab.
C
Describe your authority in moderating treatment plans, lengths of stay and the process of integrating patient, family, physician preferences and insurance priorities for payment.
D 228
How does your perception of a patient’s condition influence treatment choices made by family? Physician?
E
Describe personal reactions after conflicts are resolved that are not aligned to your personal values (end of life, futility of treatment, family or physician priorities) and knowledge of best practices.
F
Describe your self-care activities.
Describe how you might process work related ethical conflicts?
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