Innovative methods help case managers cut stress

Team management’ helps CMs share the load

One of the major reasons for the growing critical shortage of nurses is the stress that goes along with the profession. Case managers, many of whom are trained nurses responsible for nursing services, face a high rate of turnover and "burnout" as well.

"The problem is that case managers are in a job that can be called a fire station,’" says Linda Arnold, RN, a motivational expert based in Brunswick, ME.

"If there are a number of calls that come in, you have to handle them." What case managers can do is look at how they organize themselves and keep the level of stress to a minimum, says Arnold, who also is a trained psychiatric nurse.

Kathleen Lambert, JD, RN, who has been a practicing nurse for 31 years and a health care lawyer for 10, says that one of the biggest challenges facing case managers is the number of tasks they are required to perform.

Using the team concept

"Case managers are in a continuous multitasking situation," says Lambert, who spoke on legal issues affecting case managers at the 7th Annual Hospital Case Management Conference, held recently in Atlanta. One technique that she found very helpful when her patient care load got very heavy was to "team manage" with another nurse whose skills and temperament were similar to her own.

"Rather than try to carry the whole load by myself, there would be certain cases that I would team-manage with another nurse," she explains. In many instances, these were the more complex cases that required more insight in terms of what was needed for the patient.

"This gives the patients the advantage of having more than one person looking at their needs in that particular situation."

This technique also helps to protect the patient, Lambert adds. "If you get tied up with another issue for another patient, the other case did not get away from you to where you could barely catch up to it or put the patient at risk. It is an effective way of managing it, and it is very collegial."

Once a team approach is established with one patient, it’s easy to use the same approach with another patient, she adds. "The rhythm is already there."

Anne Llewellyn, RNC, BHSA, CCM, CRRN, CEAC, co-founder of Professional Resources In Management Education in Miramar, FL, says that working in a team with another case manager is especially effective if it is focused on mentoring and the value and resources that each case manager brings to the process.

"We cannot do this job in silos," she explains. "Working together with other case managers streamlines the process and decreases the fragmentation that occurs so often."

Get organized

Another technique Lambert recommends is "calendaring," which she learned as an attorney. Attorneys often work a case backward by starting with an end date and then "calendaring" what must be accomplished at certain points along the way. "You work backward to the date where you are today," she says. "That gives structure as to what needs to be done on what case."

Ellen Mitchell, MA, RNC, a case manager at Saint Vincents Hospital and Medical Center in New York City, says that she uses a similar technique involving multidisciplinary action plans (MAPs) based on diagnoses. Mitchell says when she begins her day, she looks at the census for her unit and writes lists about what those patients require that day.

"I look at it going forward on a day-to-day basis," she says. "It is almost like having your own list of things to accomplish. I call that my to-do’ list. That is how I organize my day."

Llewellyn stresses that an important part of the case management process is organization. "If case managers are not organized, they will not be able to handle their caseloads effectively and they will burn out," she warns. "Calendaring or some type of a diary system is very effective."

While there are many tools that make this task possible, case managers often have their plans interrupted by unexpected events, Llewellyn says. "Being flexible allows us to adjust our day to meet these unexpected events."

Knowing when to say no and when to ask for help is also important, she says. "If you work in an organization where there are other case managers, make sure that sharing resources and offering help is part of the culture of your case management department," Llewellyn adds.

Two important principles are to accomplish a little bit all the time, and never to let anything overwhelm you, Lambert adds. "If you just bite off a little bit at a time, it is doable. That is basically what calendaring is. It says, Here is your case; here is the endpoint. Do these little pieces along the way, and you will reach your goal.’"

According to Arnold, common-sense techniques that apply to many other professions also apply to case managers.

Case managers should understand how they react to certain situations — what she calls their "existing points of view" — and learn how to let go of the ones that are not helpful. By prioritizing and doing what is in front of them, nurses will preserve their resources, she explains.

"Nurses have a tendency to get caught up in shoulds. Sometimes, [nurses] are right that things should not be the way they are, but if that is the way they are, you use a lot of energy and cause a lot of stress by saying they should not be," Arnold says.

Some things are out of your control

Case managers also must understand what is within their control and beyond their control, she adds. "There is a difference between control’ and impact. We can all have impact by talking to the manager, but we don’t have any way to say, Do it my way.’"

"This is definitely something that nurses struggle with," Arnold says. When conflicts arise, it is useful to put it in behavioral terms rather than personalizing the situation, she says.

Seeking out continuing education is another challenge because many case management-related conferences require travel and a few days out of the hospital, Mitchell notes.

She says it often is difficult to find the time and resources to attend those meetings. "The opportunities are there, but in a large case management department, not everybody can do that."

Mitchell says she has taken advantage of many on-line educational programs.

For example, she says the New York State Nurses Association in Latham has a useful catalogue of continuing education opportunities on-line ( While they are not always specific to case managers, they do address clinical issues.

"That is where we extrapolate most of our information," she says. "Keeping current with what is going on in the clinical mainstream helps us develop the plans that we require."

Finding ways to combat stress

According to Llewellyn, case managers often fail to take time to care for themselves. "To avoid burnout and prevent illness, it is very important to look at ways that allow you to de-stress,’" she says. "Exercise, mediation, yoga, and forms of relaxation are all popular ways that you can begin to take care of yourself."

Recognizing stress and taking time out to reduce stress need to be incorporated as part of a case manager’s daily routine, Llewellyn says. It is also important for case managers to know their limits, she adds. "Many times, we as case managers feel we need be there for everyone, and we tend to forget about ourselves. Taking care of yourself allows you to be more effective for others in both your personal and professional life."

Lambert says she has known many nurses as well as lawyers who have become burned out because they focused solely on work. "If you do anything to an extreme, your brain will tell you not to do it anymore, and your body then will start to react and arrange it so that you can’t do it anymore."

"I am a firm believer that everybody should have a hobby so that you can walk away and go home and not focus on the job," Mitchell says. Case management is both a very interesting and a very difficult job, she adds. It simply is not productive to think about it 24 hours a day.

Lambert says case managers should take a holistic approach to both their life and their profession. "We are going to take on a lot of stress in a helping profession like case management. You can’t be near the fire without feeling the heat."

Lambert says that, for her, that meant developing structure in all areas of her life in order to do everything she enjoyed while maintaining enthusiasm for her profession. She started that process by listing her priorities, including her husband and four children.

Case managers who ignore the signs of stress may insulate themselves from the discomfort they are experiencing, Lambert warns. In some cases, that can lead to drug or alcohol abuse. In other cases, it may lead to procrastination. "Sometimes people will procrastinate to the point of being fired. It is a subconscious sabotage."

"Exercise is critical," Lambert says. But other tools also can help reduce stress, she adds. That might mean finding a certain kind of music that is relaxing while not intrusive to co-workers.

Massage can be another effective technique to reduce stress. "I think everyone should plan that in his or her routine at least once a month," she says. "It is amazing the energy it will give you."

Finally, case managers should not neglect their spiritual life, Lambert says. "One of the most important things in my life is my spiritual life, and I think when you neglect that, you lose a wonderful means of dealing with stress." Case managers who find a way to develop that area of their life will have another important resource to draw on during difficult times, she says.

[For more information, contact:

  • Linda Arnold, RN, Brunswick, ME. Telephone: (207) 725-6193.
  • Kathleen Lambert, JD, RN, Tucson, AZ. E-mail:
  • Anne Llewellyn, RNC, BHSA, CCM. CRRN, CEAC, Miramar, FL. Telephone: (954) 436-6300, ext. 15. E-mail:
  • Ellen Mitchell, MA, RNC, Saint Vincents-Manhattan, NY. Telephone: (718) 264-1116.]