With the rapid and complex changes occurring in health care, students preparing to assume the role of the advanced practice nurse (APN) must demonstrate expertise in the clinical practice environment while understanding the business aspect of health care. The APN is surrounded by health care business and market reforms. If APN students are to enter and survive in today's health care environment, educators must prepare them to "manage the business aspects of the professional roles they will shortly assume" (McNeil & Mackey, 1996, p. 1).
The business of health care is something all health care professionals must integrate into their professional role. Managed care has placed renewed emphasis on quality, cost-effective care. This same managed care environment has aleo created a highly competitive market for health care agencies and professionals. To survive in this environment, the APN must learn and effectively use many business skills, such as marketing, negotiation, and financial management, and gain insight into the entrepreneurial challenges of the APN role.
In addition to the business aspect of health care, the APN must have an understanding of nursing case management. Case management as a process manages resources and client outcomes to effectively care for the client and may be viewed as one effort to create order in current health care (Mahn & Spross, 1996). Some members of the nursing profession are advocating that APNs serve as nursing case managers (Pralic, 1992). While this may not be feasible at this time, the integration of managed care and case management concepts into the APN role is essential.
The graduate nursing faculty in a Midwestern, state-supported university developed and implemented an AFN graduate program. During the development phase, information from other universities, accrediting bodies, certification boards, and the local health care environment were examined. From this examination, the need for specific emphasis on business, managed care, and case management concepts was identified. To address these issues and begin to integrate business and case management concepts into the curriculum of the APN, a four-credit hour graduate nursing course was developed. The course included 3 hours in the classroom and 60 hours of clinical experience. The outcomes of this course were two-fold: to expose the APN student to business concepts associated with health care and to integrate their future role into the managed care and case management environment.
To address the business outcome, the APN students were asked to write a business plan related to health care. The students could work alone or in groups limited to three students. The students were asked to create a business that would incorporate the role of APNs and to develop a plan to implement this project. While the instructor suggested some possible projects the students might consider, the students quickly identified their own areas of interest. Some of the businesses developed by the students included nursemanaged clinics and nurse entrepreneurial projects related to case management; disease management programs; and rural health clinics. Several students in the family nurse practitioner program took this opportunity to successfully negotiate with their current health care employers the future development of a rural family nurse practitioner-managed clinic.
Because this assignment introduced several new concepts to the nursing students, a self-directed textbook was used to assist the students to work through each segment of the business plan. While the textbook gave good examples of how to address the information in each section, the examples were not health care related. Therefore, the first two class periods concentrated on introducing the sections of a business plan related to health care and the information specific to health care to be included under each section.
The students were asked to address nine sections in this business plan which included the following:
* Executive summary.
* Present situation.
* Service description.
* Market analysis.
* Marketing strategy.
* Financial projections.
The students were assigned selected sections each week. They were expected to identify and contact the people within the community and/or university who could provide the necessary information to be incorporated in each section. A draft of each assigned section was submitted to the instructor on a weekly basis. The instructor gave feedback on each section and returned the students' work during the next week. The rapid turnaround time for instructor feedback was necessary so the students could address the comments made on the draft and prepare the next sections of the business plan, which typically build on each other. Also, the instructor was able to ascertain the direction each business plan was taking. This provided the instructor with the proactive opportunity to discuss any concerns and possible modifications to the direction of the business plan. Once all of the sections were completed, a final version of the business plan with appendices and table of contents was submitted by the students.
The students were given a grade based on the completed project. The grade for those students who worked alone was instructor assessment only. Specific evaluation criteria were distributed to the students with the introduction of the project, so the students were informed of the expectations. For those students who chose to work in groups, 30% of their grade for the project was peer evaluation. Each group was asked to create their own criteria for the peer evaluation. All members of the group had to agree on the criteria submitted by the group. Each student completed a separate peer assessment for the other memberfs) of the group. The average of the points assessed to each student became the grade for the peer evaluation portion. The remainder of the grade was based on instructor assessment.
To bring this project to closure, community health care and finance professionals with experience developing, writing, and reviewing business plans were invited to give their impressions of the students' business plans. With student permission, selected business plans developed by the students were sent to the health care and finance professionals 1 week prior to being invited to a class session. The professionals gave feedback on the business plans and had the opportunity to dialogue with the students. The students also had the opportunity to ask questions of the community business people. The sharing of information and some of the experiences related to the students by the professionals added a richness to the project and gave additional credibility to the course expectations.
The writing of a business plan as an outcome of this course was most effective. The students initially felt overwhelmed and verbalized concerns that they would never be able to successfully complete the project. What they found was that they could and did succeed in completing the project while realizing a renewed interest in the business aspect of health care. Many students verbalized a broader understanding of many of the management concepts implemented in their current practice. The students had the opportunity to further develop effective communication skills as they contacted various people to gather information. Their negotiation, conflict resolution, and delegation skills were also called on as they worked with their fellow students and with members of the health care community.
They became immersed in the practice management aspects related to the role of the APN. They were asked to conduct a market analysis and develop a marketing strategy for their business, assess the resources required to begin a business, and assess the economic outlook of the geographic area in which they anticipated opening their business. They attempted to develop financial projections for the first year of business and spent considerable time identifying and assigning a monetary value or cost of a nursing task or responsibility and preparing a budget.
The business plan gave them the opportunity to more fully experience the business aspects of health care. Selected students already verbalized their interest in further development of the business plan with the intent to eventually open their own nurse-managed clinic.
The second goal of the course focused on case management and the current health care environment of managed care. The students participated in classroom discussion and clinical experiences with case managers. The intent of the case management focus was to expose students to the world of case management and provide them with the opportunity to actively participate and integrate the APN role in the current health care environment. As the students move into the APN role, they need to acclimate to the new responsibilities, recognize the influence their role will have on the current health care environment, and realize how the environment will influence them.
The classroom dialogue and clinical experiences were developed to encourage students to think of themselves as APNs. Local internal and external case managers were invited to present topics and dialogue with students. Some of the topics presented in class included outcome development and measurement, insurance information, development of an internal case management program, and negotiation skills necessary for case managers. In addition, the University and local Case Management Network offered a 1-day conference on case management. The conference featured national speakers on case management and disease management. Students were expected to attend the conference as part of the course requirements. As a result, APN students had the opportunity to hear and network with national, regional, and local case managers.
A 48-hour clinical experience was also developed for this course. The clinical experience with the case manager gave the students insight into the decision making related to the quality, cost, and access issues of managed care. Each student was linked with a case manager preceptor to meet the course's clinical expectations. The students were asked to arrange their own clinical experience if they were familiar with a case manager working in the geographic area. The instructor arranged the clinical experience if a student was not familiar with a case manager. Approximately 80% of the students did not know a case manager to contact and were subsequently placed by the instructor.
Actual clinical experiences varied depending on the type of case manager with whom the student was partnered. Students typically participated in client and physician visits, the negotiation of services, and the identification and assingment of a monetary value or cost of a nursing task or responsibility. The case managers also willingly shared their experiences in the role of case manager. All students gained a broader understanding of managed care and the case manager role, and a beginning understanding of how the APN could be integrated into the multidisciplinary health care team.
From the clinical experience, the students were asked to select one case to present to the other students in the course. Maintaining client confidentiality, each student created a case study which presented an overview of the thent and significant others, the environment, the role of the case manager in the situation, and how the APN could contribute to the case. The students were also asked to address issues such as the quality and cost of the care provided by the current health care team. Finally, each student was asked to project the influence an APN might have had on the quality and cost-effectiveness of care in the case.
Student feedback on the case management component of the course was also positive. Most students recognized how this experience broadened their understanding of the health care environment. While most students were already working in health care, they gained new insights into the complexities and significant differences the role of APNs would encompass. The students also expressed a renewed understanding and respect for the nurse case manager role. By sharing the experiences with the case manager, the students gained insight into the difficulties of their role.
The students were exposed to experiences that also built on some of the practice management issues identified by this curriculum. They experienced first-hand how nurses were able to successfully negotiate a contract for health care services. The preceptors were effective in keeping the students abreast of developments in the cases on which they were working. In some cases, the students were encouraged by preceptors to participate in the actual negotiation of services. Effective skills demonstrated by preceptors and used by students during this clinical experience included advocacy, communication, delegation, conflict management, quality management, empowerment, and prioritization.
As with any course, further development and refinement is needed. The amount of work required by the graduate students will be reevaluated. Both the business plan and case management experiences require an extensive time commitment from students and faculty. While the course expectations will not change, a more efficient approach to accomplish these outcomes may be identified.
Students who enrolled in this course gained a greater understanding of the business aspect of managed health care. They gained insight into an environment they thought they knew. They realized they needed to know a lot more before they joined the health care environment as APNs. As they continued through their course work, the concepts introduced in this course were reinforced.
The role of the APN has many advantages in the managed care health environment. Creating a learning environment that encourages active participation by the students prepares them for the health care world they will face in the future.
This course is currently taught via the Internet. Students meet three times during the 10-week session. The remainder of the course work is accomplished through computer-mediated technology, including the Internet. The Internet address to preview the nursing courses currently taught through computer- mediated instruction by the University of Southern Indiana Nursing Program is http://health.usi.edu.
- Fraiic, M. (1992). The nurse case manager: Focus, selection, preparation, and measurement. Journal of Nursing Administration, 22(11), 1314,46.
- Mahn, V., & Spross, J. (1996). Nurse case management as an advanced practice role. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach (pp. 445-465). Philadelphia: Saunders.
- McNeil, N, & Mackey, T. (1996). Marketing and teaching strategies for advances practice nursing: Proceeds of the American Association of Colleges of Nursing's master's education conference and preconference. San Antonio: American Association of College of Nurses.