By Toni Cesta, PhD, RN, FAAN
This month, we continue our discussion of the skills case managers need to perform at the highest level of quality. This issue includes information about additional communication issues and techniques that you can use to enhance your conversations with patients, families, and all members of the interdisciplinary care team.
Organizational Structural Barriers
A hospital’s organizational structure can affect the quality of communication, leading to barriers. These barriers can affect the case manager’s patients, peers, other members of the multidisciplinary team, payers, and senior administrative management.
The risk of message interruption increases with the number of people involved in the chain of communication. As in the old game of Telephone, the initial message is substantially changed by the time the message reaches the last person. Important details such as times, dates, and names are unclear. It is always more effective — and efficient — to relay the message to the entire group at once.
Defensiveness also is a barrier to effective communication. This occurs when a person attempts to protect himself or herself from a real or perceived threat. The threat could be related to the sender or receiver of the message, or it could be present in the message itself. Defensive communication can occur when there is a lack of trust, such as when a person is distrustful or suspicious of the sender’s motives. Often, the sent message contains challenging content or disregard for the receiver’s values, beliefs, or feelings.
Differences in status, such as job titles or seniority, can cause poor-quality communication. This is known as information processing or filtering. Simply being aware of and sensitive to this communication barrier can aid in overcoming it. This is common when physicians are speaking to patients, or sometimes between less experienced nurses and physicians.
Generally, there are two types of power:
- Directive power. This often is used to affect the behavior of others to satisfy personal needs.
- Synergistic power. This rallies the creative energies to benefit all participants.
Establishing a trusting relationship and knowing how and when to use power appropriately will lead to better outcomes. Case managers must share expertise, issue directives, follow up on compliance issues, and attempt to influence when necessary.
Case Study: Appropriate Use of Power on a Patient’s Behalf
Mrs. Smith, a Florida resident, was hospitalized while visiting her elderly sister in New York. After 20 days in the hospital, she is ready to be discharged. While in the hospital, her functional status deteriorated. She required oxygen and a wheelchair, presenting a potentially unsafe home situation. Mrs. Smith refused nursing home placement, wanting only to return to Florida where her friends could help her. Many contacts and more hospital days later, it became clear that it was cheaper to arrange for medical air transport to Florida than to continue her hospitalization.
The case manager in this scenario can affect the outcome of this patient’s hospitalization by using directive power and educating the hospital’s administration. Soon, it was obvious that it was financially prudent to send the patient back to Florida rather than keep her hospitalized indefinitely. The case manager’s responsibility is to communicate to hospital administration the cost-benefit of a few days in the hospital vs. the cost of an ambulance and medical air transport.
Power and Communication
Stay focused on communication goals. Do not be intimidated by the power status of the person with whom you are communicating when care quality is at stake. Seeking feedback and verifying the information conveyed will help you maintain power.
Stress and lack of trust can interfere with accurate, clear communication. Both affect the ability to express needs and share information openly and honestly. Building rapport and a trusting relationship can reduce stress, increasing the likelihood of accurate communication.
The following are four basic qualities needed for a successful patient-case manager or case manager-colleague relationship:
- Warmth. Treating others with warmth can help them feel accepted. Nurses who exhibit openness rather than cold, expressionless, disapproving behavior will gain trust faster. Warmth reflects self-respect, self-acceptance, and genuine concern for others. Patients will respond favorably.
- Respect. This encompasses the Golden Rule: Treat others as you would like to be treated. Consider the person’s personality, culture, opinions, customs, values, and beliefs. Case managers still must value and accept the patient and his or her family when their decisions about a discharge plan are not in full agreement with the case manager’s recommendations. Keeping patients informed about their care gives them the feeling they are respected as individuals, not just seen as a bed number or a disease entity.
- Empathy. This is essential to establishing a trusting relationship with a patient and family. Empathy helps people feel understood. Case managers should tune into the patient’s feelings and thoughts, and let go of stereotypes and prejudices. Case managers must hear the person without demanding he or she feel a certain way in a given situation.
- Genuineness. This component enhances the trust relationship. Remaining open and acting genuinely allows people to feel they are interacting with a real person who is interested in their well-being. Consistency often is a factor in genuineness; if a patient discovers inconsistency between verbal and nonverbal behavior, communication will break down. Remember that people who already are stressed are more sensitive to false behavior and inconsistent communication.
In addition to avoiding or minimizing the many barriers to effective communication, case managers should become attuned to communication channels that effectively transmit the message.
Communication paths can be formal or informal — and both can profoundly affect the end message. There are two types of formal communication: downward and upward. Downward communication explains what to do, how to do it, and when to complete it. This communication is common when supervisors delegate tasks to subordinates. Upward communication occurs as requests from subordinates to supervisors; for example, when a case manager speaks with a chief financial officer to request financial approval, when we decided to fly Mrs. Smith home to Florida rather than pay for her continued hospital stay. The result is a more accurate managerial process and wider participation.
Informal communication usually takes place between smaller groups, such as the case manager and the social worker. Managers in these departments might hold a formal meeting to discuss policy matters between their departments. This communication is based on mutual trust, or a more formal communication will need to follow.
In addition to reducing communication barriers, case managers can improve their communication competency. How colleagues work together as a team can determine the success or failure of any work environment. Good relationships are fostered when colleagues respect and understand each other’s responsibilities.
Generally, there are 10 elements to effective teamwork. There is a big difference between an effective team and a group of people who have been thrown together with no clear goals or expectations. While reviewing these elements, think about the members of your team, including RN case managers, social workers, discharge planners, utilization reviewers, nurse managers, payers, or physicians. Rate your team’s effort toward a productive case management program and better patient outcomes.
- Open, honest, and understanding communication;
- Common goals and clear understanding of the mission;
- Team member support;
- Pride in the team’s work and results;
- Seek and offer guidance on decision-making;
- Express ideas and opinions;
- Develop new skills;
- Use unique skills and talents;
- Engage in healthy debate and work out differences with new points of view and creativity;
- Increase openness, enthusiasm, and energy with appropriate humor.
These 10 elements require respect, compromise, and conflict resolution.
Administrative pressures for cost control while still providing safe and quality care influence case managers in their daily decision-making activities. It is more important than ever for case managers to collaborate with the interdisciplinary team to meet the pressures and demands of healthcare delivery. Case managers should remember that conflict is inevitable and need not be a negative experience. Conflict is merely a difference in views, goals, facts, or values that place them at opposite ends of an issue.
Generally, conflict falls into one of these three categories:
- Perceived conflict: The belief that a conflict exists;
- Felt conflict: The conflict causes feelings of hostility, fear, or mistrust;
- Expressed conflict: The conflict spurs debate, assertion, competition, or problem-solving.
The most widely used conflict resolution method is the collaborative win/win, where participants work toward solutions to maintain their goals and create a resolution with which everyone can live. Successful conflict management is an important skill for case managers and social workers to encourage creativity and innovation, increase productivity, and achieve goals..
The physician is a vital communication source. Patient care will suffer if there are conflicts or barriers to the case manager-physician communication. Establishing up-front communication regarding the case manager’s role is a good place to start in building an effective team among the disciplines. Case managers must initiate positive dialogue with physicians and address the stereotypes and stresses of a shifting healthcare system.
Despite sharing the common goal of delivering quality patient care, physicians and case managers can become adversaries if there is distrust of the case manager’s intentions. Comments such as “Case managers are the police who work with the insurance payers to deny care” can mean physicians perceive case managers as a threat to their medical judgment. Because of the changing working relationship between case managers, physicians, and other staff, establishing a cooperative and collaborative relationship can be awkward and frustrating.
Case managers should remember the care team is here for the patient and remain focused on that goal. Case managers should be clear their interest is in ensuring the high-quality care and the best possible outcomes for the patient and the organization. The physicians, social workers, utilization coordinators, and discharge planners should know the case managers are not there to control or dictate practice, but to foster effective, quality communication between members of the interdisciplinary care team.
Tactics for Conflict Resolution
These five tactics provide a framework for resolving conflicts:
- Competing. An assertive tactic in which an individual’s concerns are satisfied at the expense of another’s. This is useful in a situation in which the solution is urgently needed, and there is no time to try another solution.
- Collaborating. Individuals work together to find mutually satisfying solutions. This is useful when a solution is complex and requires all parties involved be satisfied with the outcome.
- Compromising. Everyone must give something up to resolve the conflict. This can be used when the goals of one individual are somewhat important or not important enough compared with the goals of other.
- Avoiding. This is a passive tactic in which an individual postpones or sidesteps the conflict. This can be used when one party holds more power, and the risk of confrontation outweighs the benefits or the solution.
- Accommodating. This occurs when an individual focuses on the concerns of others and neglects his or her own concerns. This is useful when one individual has a vested interest in the issue, while the issue is unimportant to the other.1
Communication is a key tactic that should be in every RN case manager and social worker’s toolbox. It is a skill set for success and should never be underestimated. This month, we reviewed many of the techniques that you can incorporate into your daily practice.
- Barton A. Conflict resolution by nurse managers. Nurs Manage 1991;22:83-84, 86.