By Toni Cesta, PhD, RN, FAAN

Introduction

In this month’s Case Management Insider, we will continue our discussion of the essential skills RN case managers and social workers need. Last time, we discussed the case management process and the tools and techniques needed to be effective in assessing, planning, and managing patient care, utilization management, and discharge planning. We also covered the leadership skills needed to provide the highest level of case management. This month, we will continue discussing the leadership skills and traits you need to apply every day.

Leadership and the Case Manager

If you are an RN or social work case manager, you probably do not think of yourself as a leader. You may not realize that you need some specific skills in leadership to affect your roles and functions in a positive way. In the last issue, we discussed the leadership traits of advocacy, clinical reasoning, critical thinking, and negotiation. Let’s continue our discussion of negotiation and the skills necessary to use this trait effectively.

As we reviewed, case managers negotiate when there may be differing opinions as to how to solve a problem. The negotiation may be between two other parties, or it may be between you and another individual. The other individual may sometimes be the patient or the patient’s family member. As a negotiator, you may help end an impasse preventing the patient’s care from progressing. You may have to negotiate with a third-party payer or with a physician. What are the specific skills you need to master the role of negotiator?

Negotiation Skills

Methods for better negotiation in case management are listed below. Consider how well you handle each of these and where you might need some improvement.

  • Always use clear, factual, and pertinent data.
  • Do not lose sight of the long-term goal.
  • Know the players well, including their values, beliefs, and scope of responsibilities.
  • Plan, prepare well, and practice before negotiating.
  • Always keep alternate solutions or options in mind.
  • Cultivate an interactive, collaborative relationship rather than an antagonistic relationship.
  • Focus on interests, not positions.
  • Focus on the exchange of the information.
  • Do not give up.
  • Avoid becoming emotional.
  • Trust the person with whom you are negotiating. Distrust is destructive.
  • Do not miss your chance.
  • Focus on negotiation as a process, not an event.
  • Ask questions.
  • Avoid talking too much.
  • Wait for the right moment to make your pitch.
  • Listen carefully and acknowledge the person with whom you are negotiating.
  • Brainstorm for solutions.
  • Be creative.
  • Appreciate small wins; they are as important as the larger ones.

As with any skill set, there always are pitfalls to avoid. Below is a list of the behaviors to avoid when negotiating:

  • Making the other side feel guilty.
  • Offering options that are only favorable to you.
  • Threatening the other side.
  • Using sarcasm, cynicism, or putdown statements.
  • Playing games or tricks.
  • Rushing the process.
  • Jumping at the first offer.
  • Giving away the store.
  • Trying to score all the points.
  • Distorting the facts.
  • Acting emotionally.
  • Acting aggressively.
  • Dealing with the other person as an enemy.

Your negotiations may take any of three forms:

  • Power play. With this tactic, one side makes an unfair offer expecting the other side to counter with an equally unfair offer. This assumes the stronger party will win.
  • Taking positions. Both sides dig in, taking fixed positions and making an inflexible stand. This produces a win-lose situation.
  • Collaboration. This is a problem-solving tactic wherein both sides work together to reach the best possible outcome.

Collaboration is the most desired negotiation approach. It is the only of the three approaches in which all involved can be satisfied with the outcome. It also makes the process more efficient, positive, and amicable. Avoid the other two approaches, as they can be unproductive and divisive, and may work against building teams and effective relationships. The power play approach usually is aggressive, intimidating, and condescending. In the taking positions (haggling) approach, the process of negotiation becomes a contest of wills. This is unprofessional and never a good option.

Resource Management

Clinical guidelines are useful for determining the allocated resources for a particular diagnosis. Complications, delays in care delivery, or comorbid conditions can help a case manager anticipate extra costs, such as longer hospitalizations, expensive antibiotic treatment, or pain management.

The case manager plays a key role in communicating the overuse of lab tests and repetitive diagnostics, or the underuse of cheaper antibiotics. Case managers can ensure delivery of high-quality of care while being more cost-efficient in the process. One of the driving forces behind every great case manager is maximizing patient outcomes and quality of care while staying aware of dwindling resources available to provide that care.

Patient and Family Education

Another leadership skill is that of educator. This is a big responsibility because it covers a broad array of educational needs as patients transition toward discharge. Educating the patient and family is a key element of a successful discharge and maintenance in the community. It is important that case managers consider the patient’s language, cultural diversity, and healthcare beliefs. In our constant awareness of the pressures to reduce length of stay, education is sometimes missed or neglected. Nevertheless, timely education is crucial, especially as patients experience shorter hospital stays. Placing education at the bottom of the priority list can have devastating effects on outcomes.

For example, a family decides to care for their loved one, who is dependent on a ventilator, at home. Home care plans are arranged: the respiratory company has been contacted, the home is prepared, and the nursing visits are on schedule. Everything seems to be ready, but a crucial element is missing: No one taught the family how to care for the patient at home, ventilator function, or resuscitation. Without education, the discharge plan runs the risk of failure, costly extra days in the hospital, or potential readmission due to the family’s lack of knowledge and their inability to handle the patient’s care.

Do the patient and family respond better to verbal or nonverbal communication, audio or video, written words or pictures, discussion, or demonstration? Understanding the most effective ways to educate the patient and family is an important component of the process. The other critical component is repetition. Since patients may be sedated, in pain, or not feeling well, they may not be able to absorb lots of information in short periods. They also may experience issues with health literacy. Understanding the patient’s situation will inform the best ways to educate them. Start any educational process with an assessment of the patient’s readiness to learn and ability to understand and retain the information.

Communication and Interpersonal Skills

Communication and other interpersonal skills are the lifeline that connects us to our world. Good communication is essential as the technological world moves faster. Communication is a core managerial function for good leadership and decision-making. As managers and leaders, case managers must master effective communication to be successful.

Communication is the transfer of information, ideas, understanding, or feelings. Case management is working with and through others. Communication is necessary so that each person knows his or her role in the process of accomplishing goals.

In the role of a case manager, communication should not be treated lightly. Miscommunication can lead to poor outcomes for a hospital, payer, patient, or family member. It is easy to miscommunicate: At any point, external issues — or “noise” — can interfere with effectiveness, clarity, or accuracy. Noise can be physical, such as he beeping of cardiac monitors; psychological, including fear or anxiety; or anything else that distracts from the information presented.

Communication includes four elements. The first is the sender, who communicates the message. The second is the message, including verbal and nonverbal communication. The third is the receiver. If all goes well, the message received will be the intended message sent. The fourth component is the context of the message. Context includes the patient’s condition, cultural background, health beliefs, and values. These elements must be tailored to the person receiving the message — in this case, the patient. Consider the patient’s preferred method of communication, readiness to learn, and receptivity to the message.

Physical Barriers to Learning

Case managers must use every means of assessing patients’ readiness to learn and/or potential barriers to learning. The preferred and most appropriate method of education must be determined.

The first step is to ensure the patient receives the message. The case manager must take full responsibility for reducing physical barriers to communication.

Consider this case study: The case manager enters Mrs. Smith’s room to discuss her discharge plan. Her TV is on, two visitors are present, housekeeping personnel are emptying the garbage, and the lunch carts are rolling down the hall. Very little effective communication will occur unless the physical barriers are removed. First, ask the patient’s permission to turn off the TV. Next, invite visitors to participate in the meeting if agreeable to the patient and appropriate for the meeting. Then, explain why you are there and make eye contact. If distractions remain, wait until the housekeeper has left the room and the dietary cart has passed in the hallway. Then you can proceed because you have taken control of the physical environment and reduced the physical interference that would have negatively affected your communication effort.

Psychological Noise

The root cause of psychological noise is distraction. Anxiety, depression, anger, hunger, medication, and fear can affect how much information the patient understands and retains. Methods such as the teach-back method, asking for feedback, and providing feedback can identify psychological noise or barriers to learning.

Barriers to Information Processing

The human brain can take in large amounts of data but can only consciously process one thought at a time. Communication overload is a classic example of a processing barrier. A person becomes overloaded when too much information is sent at once. The receiver then becomes overwhelmed and shuts down.

An example of this is teaching a patient to test his or her blood sugar. The nurse recites the process: pricking the finger, dabbing blood on the test strip, and feeding the strip into the glucose monitor. If the information is explained too quickly, the patient may become overwhelmed and shut down.

Perceptual Barriers

Everyone brings a unique set of experiences to communication that influences how he or she perceives the communication. We interpret everything we experience from our vantage point and past experiences. We tend to assume that the way we see things is the way that they really are and the way everyone else sees them.

Handling Psychological Barriers

Consider this case study: A case manager approaches Mr. Jones, an 80-year-old man admitted for dehydration and intractable diarrhea. Asking “How are you today, Mr. Jones?” elicits a nonverbal response of sighing and wringing his hands, but a verbal response of feeling fine. His expressions and actions do not match his verbal reply, and the case manager interprets this as anxiety. The case manager probes further and learns he is exhausted and preoccupied with his daughter and son-in-law, who are “after his money.”

This may not be the best time to explain discharge planning options to Mr. Jones, as he is grappling with a clear psychological barrier: his relationship with his daughter and son-in-law. He may believe that discussing personal or family problems with a nurse is inappropriate. Before discussing his personal life, the case manager should establish trust to help him feel more comfortable. Beginning with a less emotionally charged topic would be advantageous in building rapport and becoming better informed about this patient. The case manager would be more successful when approaching this sensitive subject with him in the future.

Summary

This month, we continued our discussion of the traits and skills needed to be an effective case manager. Next month, we will dig deeper into the role of communication in successful case management.