How Community Matrons Perceive Their Effectiveness in Case Management, Article Critique Example

Nursing research is composed of many different methodologies.  In addition to the typically used quantitative studies, nursing research has also effectively used qualitative research methods.  Qualitative research methods differ from quantitative research methods in a number of key areas: 1) Qualitative methods usually examine a smaller size than quantitative methods; 2) Qualitative methods do not apply statistical methods to data; the data gleaned from qualitative studies usually focus on analyzing words and themes spoken by subjects; 3) Qualitative methods are often used in the initial stages of understanding a research question, the data can then be used to formulate hypotheses for a quantitative study.  In this paper, I will do a quantitative/qualitative critique of a research study performed by Grange (2010) on the impact of community matrons in case management.

Purpose and Problem

The authors of the article clearly state the purpose and problems of the study.  The purpose of the study is to explore community matrons’ experience of caseload management and identifying situations that may restrict or enhance patient care and outcome (Grange, 2011).  Although the Department of Health provides an ad hoc case load of 50, there is no robust evidence in the literature to justify this number.  The article addresses a main problem in the care of older individuals with chronic conditions that spend many years in the health care system: That is, although there are many care givers in this type of patient’s life, there is not one advocate that is aware of the patient’s preferences, guiding him/her through the system. Many have conceptualized that community matrons could potentially fill this important role in the health care system; however, there is little evidence understanding the case load such an individual should take on.  In particular, the UK needs to establish guidelines as the notion of community matrons was imported from the United States.  The goal of this study, therefore, is to understand what the caseload and role should be for community matrons.

Literature Review

The study contains a short but ultimately relevant literature review.  The literature review contains a total of eleven references; of the cited references, roughly four are sooner than five years old; the rest are older than 2005.  The references come from a variety of publications: A majority of the citations come from journals related to nursing, and in particular gerontological nursing.  There are also a number of articles from policy related documents (government plans, etc); the emphasis on distilling existing policy is important in understanding how health care administrators envision the role of community matrons in the health care system

While there are a number of studies that focus on either the role of community matrons or their case load; few focus on linking the case load with the goals and work demands of the position.  Citing one meta-analysis review, there were a total of 14 case management studies that reported overall results: only two reported significant reductions in hospital admissions (Huff et al., 2004).   Although this is a positive outcome, the article points out that a falling admission rate may or may not be related to the use of community matrons (Kane, Keckhafer, Flood, 2003).

Further, case management methods are not homogeneous further intensifying the difficulties in understanding how case management method interacts with other factors in the hospital (Kemper, 1998).  There are also differences in the model that make generalizing results difficult: While the US model is based on the Evercare model (in a long-term care setting), the model in the UK will be used on patients living by themselves, without substantial institutional support (Kane, Keckhafer, Flood, 2003).  There does not appear a consensus regarding how community matrons affect health care, and their ultimate effectiveness in reducing admissions and length of stay (Laramee, A., Levinsky, S., Sargent, J, 2003).

Research Design/Theoretical Framework

Qualitative methods, focusing on phenomenology analysis or interview data, are the main theoretical framework used in the study (Grange, 2011).

Sample Size  

In total, there were 29 community matrons based in two southwest PCTs (Grange, 2011).  Once the exclusion criteria were applied, including those who had not worked longer than a year, six community matrons were ultimately interviewed. Although this is an extremely small sample size, the authors make the case (somewhat unpersuasively) that the sample reflected the maximum variation for other variables including geography, differences in age, and experience in the field.

Procedures for Data Collection

In order to successfully implement the phenomenological interview method,  the researcher conducted one-semi structured interview with  the participants for roughly 60 minutes (Grange, 2011).  There were four main purposes of the interview: 1) Determine the challenges of community matrons faced in building a caseload; 2) Identify the impact of case management in preventing admissions/ reducing length of stay; 3) Highlight how managing a caseload could be improved (Grange, 2011).  The data were ultimately organized and classified according to different themes; once the themes were identified, they were coded and sub—coded (Grange, 2011).

Data Results

Since the main data collected in the study were qualitative (interview) data rather than quantitative data, there were no statistical tests conducted.  Rather, the results of the interview were analyzed to find prevalent themes.  In particular, the interviews indicated that experience on the job was not a prominent factor in assessing how effective a community matron could manage the caseload (Grange, 2011).  On the other hand, geographical area, in the opinion of the interviewees, did have an influence on the overall case load.   Among those interviewed, some concerns were expressed with those community matrons managing in excess of 80 patients:  Community matrons stressed the significant effort it took to understand the complex medical needs of each patient; the ability to achieve  that level of detail for 80 patients concurrently was not deemed possible (Grange, 2011).    Community matrons also viewed their role as more active in nature: helping the hospital and doctors understand the patient’s history and the potential benefits and costs of any hospitalization.

The interviewees viewed issues such as remote access, ability to access patient’s records, and increase in the amount of resources available positively; a 24-hour admission service was also thought to be an idea worth exploring (Grange, 2011).  The community matrons main expressed fear was an elevation of their role as a “manager of the care team”; such a role would only detract from their expertise in assessing clinical care.  Finally, community matrons were neutral about their ultimate ability to prevent unnecessary hospitalizations; this was because one could not actually prove whether the hospitalization was needed or not.

Study Findings

Overall, community matrons saw a lower number of caseloads as more positive: A range of 20-40 cases per community matron was seen as optimal (Grange, 2011).  The interviewees also expressed difficulty in quantifying their role and ability to prevent hospital admissions.  Since there is significant variation in the number of patients and their condition, this is another confounding factor in the analysis.   The other main finding that participants found their role being reduced to more reactive in nature with an increase in case load was also echoed in previous studies.

Study Limitations

The authors pointed out a number of study limitations.  The researcher admitted she was in the field and could have numerous biases and preconceptions that may have unduly influenced the results through how the research was design and ultimately implemented.

Replication:

There is academic reason to replicate this study, perhaps with a larger sample size in order to garner more diverse opinions and test existing results.  Due to the nature of qualitative studies, and the differences in the population, however, there is no guarantee that the findings will be replicated.

Conclusions:

This research article written by Grange entitled “How community matrons perceive their effectiveness in case management” is an example of a qualitative research study.   The strengths and weaknesses of the article are connected to the method chosen.  Advantages of the qualitative method include the robust texture gleaned from interviews, the ability to explore previously unexplored questions, and the flexibility of questioning and analysis. Weaknesses of the method include a small sample size, the lack of statistical analysis, and the difficulty generalizing results to a larger population.  In spite of these limitations, however, the author’s decision to choose the qualitative method was appropriate: This is because the author was trying to obtain a baseline understanding of an emerging phenomenon without extensive research performed. The author thus obtained valuable results that can be used as guidance for a more robust quantitative study.

References

Grange, M. (2011).  How community matrons perceive their effectiveness in case management. Nursing Older People, 23(5), 24-29.

Hutt, R., Rosen, R., McCauley, J. (2004). Case-managing Long-term Conditions: What Impact Does it Have on the Treatment of Older People? King’s Fund, London.

Kane, R., Keckhafer, G., Flood, S. et al. (2003). The effect of Evercare on hospital use. Journal of the American Geriatrics Society, 51 (10), 1427-1434.

Kemper, P.  (1998). The evaluation of the National Long Term Care Demonstration: overview of the findings. Health Services Research 23 (1), 161-174.

Laramee, A., Levinsky, S., Sargent, J. et al. (2003). Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Archives of Internal Medicine. 163(7), 809-817