Objectives: The Ontario Workplace Safety and Insurance Board (WSIB) introduced Nurse Case Managers (NCMs) in order to improve early injury management and promote better coordination of efforts among service providers. The introduction of nurse case managers provided the impetus for a formative evaluation of the role and an opportunity to test the propositions in the Nursing Role Effectiveness model. The objectives of this study were to examine the factors that influence the development and implementation of the NCM role, and advance testing of the propositions in the Nursing Role Effectiveness model by examining the influence of a broader set of structural variables on nurses' role performance in an ambulatory practice setting.
Design: A descriptive, cross-sectional, multiple method design was used to collect data on the NCM and WSIB structural variables and role performance variables.
Population, Sample, Setting, Years: The setting for the study was the Ontario Workplace Safety and Insurance Board. The population was NCMs employed a minimum of three months. Data were collected from a random sample of 157 NCMs, 156 team members, and 102 workplace representatives who had directly or indirectly received services from a NCM. Data collection occurred in 1999-2000.
Variables: The Nursing Role Effectiveness model was adapted to the practice situation of the nurse case manager. The NCMs' structural variables included length of experience in the role, educational preparation, and confidence in the role. The WSIB structural variables included industrial sector, receptivity to the role by other team members, perceived barriers to role implementation, opportunities for professional development, role formalization, role tension, and autonomy in the role. The process variables in the framework represent the role responsibilities in which NCMs engage. A clinical diary of NCM role activities indicated that NCMs most frequently engaged in coordinating care for the injured workers. Therefore, the process variables included in this study were coordination strategies used and perceived effectiveness of care provided to injured workers.
Methods: A self-report questionnaire was used to collect data on NCMs length of experience in the role, educational preparation, and industrial sector. Data on receptivity to the role and confidence in the role were collect from NCMs using a self-report measure developed by Sidani et al. (1997). Cronbach's alpha was 0.83. Data on barriers to role implementation were collected by asking NCMs to rate the extent to which each factor on a list interfered with their ability to carry out case management functions. Lyon's role tension scale was used to collected data from NCMs on role tension (Cronbach alpha 0.82). Hackman and Oldham's Job Characteristics survey was used to collect data on job autonomy (Cronbach's alpha 0.68). Data on the quality of coordination activities were collected from NCMs and team members (Cronbach's alpha ranged from 0.56 to 0.89). The effectiveness of NCMs care to injured workers were collected from three sources using an instrument developed by Shortell et al. (1991). The three sources were NCMs, team members within the WSIB, and workplace personnel. Cronbach's alpha ranged from 0.77 to 0.92 for the different sources.
Findings: NCM's view of coordination effectiveness was predicted by NCM's educational preparation, the sector in which they worked, and receiving adequate financial reimbursement. Team members' view of coordination effectiveness was predicted by NCMs' educational preparation, which had a positive effect, and lack of role acceptance, which had a negative effect. NCMs' perceived role effectiveness was predicted by years in nursing, role formalization, lack of overlap in roles, independence in the role, and having adequate clinical training for the role, which had positive effects. Team members' view of role effectiveness was predicted by receptivity to the role, having adequate preparation for the role, and having adequate reimbursement. Workplace personnel's perception of role effectiveness was predicted by NCMs' job autonomy, which had a positive effect, and role formalization that had a negative effect.
Conclusions: The study results offer empirical validation for the propositions in the Nursing Role Effectiveness model and indicate that it is a useful framework for evaluating advanced practice roles such as the NCM role.
Implications: The study advances our understanding of the structural variables that influence nursing role effectiveness. In particular the findings underscore the importance of educational/clinical preparation for advanced practice roles, the impact of team members' receptivity to the practice role, and the need for adequate financial remuneration for the role.
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