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Is managed care education for new nurses adequate?

Nursing practices have been affected by managed care at all levels, from nursing administration to direct patient care, causing one to ask if new practicing nurses receive adequate managed care education. A search of the literature published between 1982 and February 2006 was conducted using ProQuest, Article First, ERIC, and PubMed. The literature primarily comprised anecdotal articles; only two qualitative research-based studies were published. The search revealed nurse employers and nurse educators believe that managed care competencies are very important for new practicing nurses, but even with curricula changes, managed care competencies are deficient for new practicing nurses. Further research is recommended to identify the specific managed health care education that would be effective in preparing new practicing nurses for today's health care arena at all levels of nursing.


The potential to control health care costs was one of the main factors that led to the popularity of managed care. (1) The managed care concept has been applied to public health care in the 1980s and 1990s (Medicare and Medicaid, respectively). Today, the Medicare Advantage program is receiving increasing attention as a possibly attractive option for seniors.

As increasing numbers of Americans enrolled in managed health care plans, it would have been expected that managed care education be taught in this nation's schools of medicine and allied health professions. The ramifications of managed health care began to affect the nursing practice by the early 1990s.

From the perspective of nursing education, health plans have sought nurses to fulfill newer, nontraditional roles, such as medical case management and utilization review. (2) However, nurses have been caught between managed health care's economic cost-saving strategies and the provision of quality care for their patients. (3) Even in the advent of these changes, however, nurses have received little formal education regarding managed care concepts. The purpose of this article is to review the literature and evaluate if adequate managed care education is available for new practicing nurses.


A literature search, which included business and medical science databases between 1982 and 2006, was performed using the key phrase, "managed care and nursing education." The databases accessed were ProQuest, Article First, ERIC, and PubMed; the search yielded less than 12 articles.


The manuscripts retrieved were primarily editorial and included two qualitative research studies. (4,5) Two articles (4,6) were based on the same study, whereas another two (7,8) were based on the nurse case managers' educational preparation. One of the qualitative research articles was based on a survey of nursing baccalaureate programs to discover curricula changes related to managed care that were made from 1994 to 2001. (5) Two key issues were identified in the literature: (1) a need exists for managed care education for new practicing nurses as identified by nurse educators and nurse employers and (2) nursing school faculty are not adequately fluent in managed health care. The literature revealed that nurses are needed in multiple roles for MCOs, and that these organizations must train their newly hired nurses themselves, owing to a lack of appropriate managed health care education or experience.

The need exists also for nurse case managers as a result of the growth of managed care. (9) Other managed care roles for nurses include risk manager, utilization review, quality assurance coordinator, patient relations, and provider relations. (9)

The existing literature reinforces the notion that the implications of managed care on patient care are very important to nursing education. Nurse educators must consider the trends in health care when designing nursing curricula to meet the needs of patients. Broader approaches to patient care must be addressed, including case management, health care reimbursement affecting treatment decisions, managed care acronyms, and the implications for nurse practitioners as primary care providers.


One of the top educational needs of nurses, as identified by nurse case managers, is third-party reimbursement. (7) Fletcher and Coffman (8) suggested that an elective course in nursing practice as a case manager should be more widely available in nursing school curricula. They reported that three nursing schools in South Florida implemented a curricula development project that emphasized managed care competencies. The project was the creation of a case management course to be offered in the last term of a bachelor of science in nursing (BSN) program or at the master of science in nursing (MSN) education level. Seven modules to the course were developed, but only one of the three schools in South Florida adopted the course. The other two schools taught portions of the developed course. Even though some nursing schools had incorporated managed care curricula, the classes were solely case manager focused. Many other areas of nursing should include managed care competencies courses to make them more effective and useful.

From 1995 to 2000, managed care trends affecting nursing education have changed very little. Heller and colleagues (1) found that controlling health care costs was one of the factors that led to the popularity of managed care. Nurses have taken the lead in health education and health promotion for patients; however, these areas are poorly funded or reimbursed by MCOs. (10) Nursing schools must prepare students for all levels of roles in the managed care environment, from case managers to advance nurse practitioners hoping to receive reimbursements for their services. (11)

The Texas Department of Insurance (TDI) and the Texas Nurses Association (TNA), both in Austin, collaborated to help expose registered nurses to the issues facing patients in an HMO. (11) The Department of Insurance investigated health insurance plan complaints from patients. The project's goal was to teach registered nurses to understand how MCOs work as part of their practice. With a grant from the Texas Insurance Association, seven nurse interns in MSN-level programs were hired between 1997 and 2001.

These nurses reviewed enrollee complaints from various HMOs operating in Texas. They also shared with their colleagues their knowledge of the managed care environment. One intern went on to use what she learned in a pediatric nurse practitioner role with patients who have cancer to help them effectively navigate the health care system through their course of illness. Another intern became a nurse consultant for TDI after her MSN completion to help the organization perform mock audits of HMOs.

A pivotal, qualitative study by Brzytwa and associates (4) assessed nursing leaders' perceptions of the importance of 19 managed care competencies. The study, funded by the Robert Wood Johnson Foundation (Princeton, NJ), was based on 292 survey responses from more than 1,000 distributed surveys. The researchers found that nursing leaders in the education and employment fields perceive a deficiency in managed care knowledge among new practicing nurses, regardless of two-year or four-year educational program. They also found educators and employers perceive that having a knowledge of managed care at the time of graduation is very important; however, little nursing curricula were devoted to managed care education. Accredited nursing programs focused on direct bedside patient care competencies and the associated theories. In addition, the nursing leaders could not agree on when to introduce managed care knowledge into nursing education.

Nurses play crucial roles in managing chronic illness and its associated cost, but they receive little formal training to do so. (6) Resources are shrinking while the acuity of patient illnesses is growing.

In 2003, additional analysis was performed by Copeland and colleagues (6) based on the original 2000 qualitative research collected by Brzytwa and associates. (4) Researchers discovered that the majority of nursing schools surveyed did not work with MCOs to develop managed care education programs for nurses. (6) No significant differences were found between BSN and MSN programs among the nursing schools included in the study.

However, some schools did collaborate with physician training programs in managed care education. The concern is that the physician training and managed care competencies may be different than nursing managed care competencies. Nursing curricula should be based on valid nursing research regarding the specific managed care competencies that are needed for new practicing nurses. This must be implemented from the nurses' point of view.

Fifty-seven percent of MCOs employing nurses offered managed care education to their workforce. (6) This may have been because of the lack of preparation at nursing schools levels. Employers primarily developed managed care training programs themselves or outsourced the training to consultants.

On average, 77% of nursing school faculty indicated they were deficient in their knowledge of managed care. (6) This percentage was similar in states with high or low managed care penetration. (6) Of the schools that incorporated some managed care education, the curricula contained these topics:

* Payer differences

* Ethical issues

* Models for efficient use of resources across the continuum of patient care

* Credentialing

* Case management

* Allocating funds in capitation

* Definitions of nursing practice outside of the hospital

* Definition of terms

The educators surveyed in this study (6) suggested managed care education should be incorporated into nursing curriculum and that a need exists to improve faculty knowledge of managed care. They noted that this could be accomplished through collaboration with MCOs. Infrequent collaboration with nursing schools and MCOs resulted from minimum working relationships with MCOs and nursing faculty.

At least five explanations exist for not including managed care education in accredited nursing programs: (1) the lack of time and resources for another core competency in nursing school curricula; (2) too few "source experts" in nursing faculty to include a course for managed care competencies for all accredited programs; (3) managed care education is ranked as low priority in nursing education; (4) overwhelming research and teaching demands, making self-development in a new area of expertise extremely difficult; and (5) resistance to change in the traditional nursing curricula.

Research revealed that approximately 40% to 60% of 66 surveyed BSN nursing programs had altered their curricula between 1994 and 2001 in an attempt to accommodate the entrance of managed care into the health care industry. (5) However, according to Brzytwa, (4) 152 surveyed nursing employers and 140 nursing educators in 45 states perceived a deficit of managed care knowledge among new practicing nurses.


The practice of nursing continues to evolve with the changing health care market. Managed care organizations and the understanding of these groups is becoming increasingly important to new practicing nurses. Evidence that these nurses are adequately educated about managed care is lacking. The literature substantiates the need to teach and promote managed care competencies among new practicing nurses. Both employers and educators believe in the concept of improving managed care knowledge for new nurses. The inadequate faculty expertise, lack of relationships with MCOs, and the paucity of research on the topics that must be covered are some of the barriers preventing nursing schools from incorporating more managed care education into their curricula. Since few source experts currently exist in the nursing faculty, innovative partnerships between MCOs and nursing programs can help provide some managed care education for nurses. However, the majority of managed care education for new nurses comes from on-the-job training offered by the MCOs themselves.


(1.) Heller B, Oros M, Durney-Crowley J: The future of nursing education: Ten trends to watch. Nurs Health Care Perspect 2000;21:9-13.

(2.) Browne R, Biancolillo K: The integral role of nursing in managed care. Nurs Manage 1996;27:22-24.

(3.) Turkel MC: Struggling to find a balance: The paradox between caring and economics. Nurs Adm Q 2001;26:67.

(4.) Brzytwa E, Copeland L, Hewson M: Managed care education: A needs assessment of employers and educators of nurses. J Nurs Educ 2000;39:197-204.

(5.) Jackson S: The influence of managed care on U.S. baccalaureate nursing education programs. J Nurs Educ 2006; 45:67-74.

(6.) Copeland HL, Brzytwa E, Blixen C, et al: Managed care education for nurses: Practices and proposals. Nurs Econ 2003;21:24-30.

(7.) Nolan MT, Harris A, Kufta A, et al: Preparing nurses for the acute care case manager role: Educational needs identified by existing case managers. J Contin Educ Nurs 1998;29: 130-134.

(8.) Fletcher IL, Coffman S: Case management in the nursing curriculum. J Nurs Educ 1999;38:371-373.

(9.) Conway-Welch C, Norman L: Health care reform and managed care: Challenges for nursing education. Qual Manag Health Care 1995;4:34-39.

(10.) Huston C, Fox S: The changing health care market: Implications for nursing education in the coming decade. Nurs Outlook 1998;46:109-114.

(11.) Fitzgerald ML, Crismon C: Nurses in managed care roles.Tex Nurs 2001;75: 11,13-14.


Ms. Reneau has indicated that she has no relevant financial or commercial affiliations to disclose.

Address for correspondence: Margaret Reneau, MSN, RN, 388 St. Johns Golf Drive, St. Augustine, Florida 32092. E-mail:

To obtain reprints, please contact Kevin Chamberlain at (914) 337-7878 ext. 202 or visit our website at Copyright 2006 by Medicom International. All rights reserved.

Ms. Reneau is a Doctor of Philosophy candidate in Nursing Education, University of Northern Colorado, Greeley.
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Author:Reneau, Margaret
Publication:Managed Care Interface
Geographic Code:1USA
Date:Nov 1, 2006
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