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Telephonic response to workers in crisis
PROFESSIONAL DEVELOPMENT by Janet R. Appelhans, RN, BS, CCM, and Sylvia Kupferer, RN, MS, NCM
A
crisis by definition is a temporary situation, a turning point, an emotionally significant event signaling emotional
distress, an unstable or crucial time or state of affairs.1 Given the instability at the moment of crisis, the outcome can be resolved with either adaptation and coping or continued distress and dysfunction.2 The case manager can assist the injured worker in these situations with basic communication skills and provide support, information, and assistance with problem-solving.
In the workers’ compensation field, the case manager is always dealing with a potential situational crisis. The work injury may precipitate a crisis and be related to loss of health, potential loss of ability to return to the same work situation, or loss of social supports, financial issues, or self-image. How the injured worker deals with the situation will depend on many factors. Murry and Huelskoletter3 identify the following important factors: • Perception of the event: Depending on the individual and his unique past experience, the work-related injury may represent just another bump in the road or may threaten self-concept, self-expectation, or expectations for the future or be a source of shame. • Perception of dependence on the work situation or the lost object: Some March/April 2002
TCM 53
workers are injured again as a result of efforts to get back to work too early because of the value that working represents. • The severity of the injury and the degree to which the injured worker believes he will be able to work through it and return to preinjury functioning • Personal maturity and coping skills, especially if those skills include the ability to reach out to others (eg, family, friends, and professional caregivers) for assistance • Previous experience with similar situations: We learn from the past; the second time around, the worker can draw on previous experiences and may feel more in control if the experience was positive. Or she may feel very stressed if the previous experience was negative. • The realistic impact of the injury in terms of how it will affect the worker’s lifestyle • Cultural influences:4 Although the case manager needs to proceed with caution in this area, certain generalizations can be made based on the individual’s cultural background. • Availability of resource people (eg, family, friends, coworkers, and employee assistance programs) who can positively affect outcome Telephonic Intervention Our telephonic workers’ compensation case management (CM) unit at The Hartford recently received full URAC accreditation. Nurse case managers must be aware of and comply with the URAC standards to obtain this accreditation. One of these standards specifically says the CM organization shall establish policies and procedures to protect the safety of clients and case managers. When this policy was introduced to our staff, we discovered an opportunity to help our telephonic nurse case managers become more comfortable speaking with injured workers. Specifically, this training will be useful if they believe the worker is in crisis and safety has become an issue. TCM 54
March/April 2002
The most common safety issues involve situations in which the worker either speaks about doing harm to him- or herself or others. In these situations, the case manager must gather as much information as possible about the individual’s intent and surrounding circumstances. Only when this information is known can urgency be evaluated and a course of action be determined. When an injured worker calls in crisis, the case manager must be able to use basic communication skills. If the injured worker has no readily available family or community supports, a call to the case manager can be invaluable. The role of the case manager in this situation is to listen, support the worker, and provide information and referrals as needed. The caller in crisis may not be able to logically reason out a plan to address the problem for which he is calling. Wilson and Kneisl5 group callers into one of four categories: crisis calls, ventilation calls, combination calls, or informationonly calls. Ventilation calls may address issues related to anger about treatment, lack of progress, continued pain management issues, return-to-work issues, and frustrations in navigating the health care and worker’s compensation systems. These calls are best managed by empathetic listening and information sharing. This approach may sound simplistic, but dealing with the anger that comes from frustration can be very challenging, especially if the injured worker has learned to get what he wants by being demanding, aggressive, cursing, and threatening. The key to managing these calls is to remember that the injured worker is reacting to not getting his needs met in the only way he knows how to react. A common mistake that case managers make is taking offense to the anger as if they were responsible for it in some way. It is not necessary to defend the employer, company, physician, or other individuals. Instead, they should listen and work toward helping the individual cool off enough to think clearly and look at ways he can solve the problem. For a true crisis situation, communication needs to be more direct and requires more specific management.
General rules include the following: • Keep your voice and messages to the injured worker calm. Sounding upset or worried can escalate the situation. • Determine if the injured worker is in a situation in which he may harm himself or others. Ask questions about this simply and clearly, “Are you saying that you plan to injure yourself or your employer?” • Use active listening techniques, such as open-ended questions, “Tell me what you are thinking of doing.” Then paraphrase the worker’s answer to be sure you understand the message. Identify feelings of anger, frustration, depression, and such that may not have been expressed. • Problem-solve with the individual. If immediate action is needed, have a coworker assist you by getting help to the injured worker (ie, notifying police or emergency services) or alerting appropriate management staff according to policy. • Talk with the worker about a safety plan. Much has been written about developing a contract for safety, and realistically, it does work sometimes.6 Talk about specific solutions. Get the injured worker to make a written list of possible actions he could take, people to call, places to go for help, etc. Give information and assistance that may be available. The communication and actions taken during these calls must be documented in the injured worker’s file. Remember, legally speaking, if it was not documented, it was not done. The nurse may want to check over documentation or ask a supervisor for assistance in ensuring that the report is factual, concise, and appropriate. The nurse case manager should realize that many employers may have access to information regarding their employees’ worker compensation injuries and, in some cases, even the file containing this information. This access should be taken into account along with privacy laws when documenting interactions with patients. For example, the injured worker may speak of nonwork-related issues and perhaps
other issues related to his workers’ comp injury. It may be best for you to refer directly to the work-related injury issues and then address the injured worker as also having mentioned personal issues that he is upset over.
Follow-up also allows the case manager to determine if any further action is needed. This follow up also can help strengthen the case manager’s relationship with the injured worker because it reinforces the advocate role.
After you have handled the situation, debriefing with a colleague or supervisor is always a good idea. Give yourself an opportunity to go back over the situation. This review will serve both to decrease the stress that will accompany handling these calls and help you look at things you may want to do differently the next time you get a call from a worker in crisis.
After all is said and done, it is important for the case manager to realize that the injured worker is responsible for his own decisions. However, by following company policies based on URAC standards as we do at The Hartford, our nurse case managers can believe they have dealt with what can be difficult situations to the best of their professional abilities. ❑
The final step in this process is to follow up with the injured worker the day after your communication or at the time you indicated you would do so based on the urgency of the situation. This follow-up is important so that the nurse case manager may determine if the injured worker has obtained the assistance or taken the actions that he indicated he would.
References 1. American heritage dictionary. 2nd ed. Boston: Houghton Mifflin; 1982. 2. Caplan G. Principles of preventive psychiatry. New York: Basic Books; 1964.
3. Murray R, Huelskoletter M. Psychiatric/mental health nursing: giving emotional care. Norwalk: Appleton & Lange; 1991. 4. Lassiter SM. Multicultural clients. A professional handbook for health care providers and social workers. New York: Greenwood Press; 1995. 5. Wilson H, Kneisl C. Psychiatric nursing. Menlo Park: Addison-Wesley; 1996. 6. Egan M. Contracting for safety: a concept analysis. Crisis 1997;18(1):2. Janet R. Appelhans, RN, BS, CCM, and Sylvia Kupferer, RN, MS, NCM, are case managers for The Hartford in Aurora, Ill. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/123060 doi:10.1067/mcm.2002.123060
March/April 2002
TCM 55
A
crisis by definition is a temporary situation, a turning point, an emotionally significant event signaling emotional
distress, an unstable or crucial time or state of affairs.1 Given the instability at the moment of crisis, the outcome can be resolved with either adaptation and coping or continued distress and dysfunction.2 The case manager can assist the injured worker in these situations with basic communication skills and provide support, information, and assistance with problem-solving.
In the workers’ compensation field, the case manager is always dealing with a potential situational crisis. The work injury may precipitate a crisis and be related to loss of health, potential loss of ability to return to the same work situation, or loss of social supports, financial issues, or self-image. How the injured worker deals with the situation will depend on many factors. Murry and Huelskoletter3 identify the following important factors: • Perception of the event: Depending on the individual and his unique past experience, the work-related injury may represent just another bump in the road or may threaten self-concept, self-expectation, or expectations for the future or be a source of shame. • Perception of dependence on the work situation or the lost object: Some March/April 2002
TCM 53
workers are injured again as a result of efforts to get back to work too early because of the value that working represents. • The severity of the injury and the degree to which the injured worker believes he will be able to work through it and return to preinjury functioning • Personal maturity and coping skills, especially if those skills include the ability to reach out to others (eg, family, friends, and professional caregivers) for assistance • Previous experience with similar situations: We learn from the past; the second time around, the worker can draw on previous experiences and may feel more in control if the experience was positive. Or she may feel very stressed if the previous experience was negative. • The realistic impact of the injury in terms of how it will affect the worker’s lifestyle • Cultural influences:4 Although the case manager needs to proceed with caution in this area, certain generalizations can be made based on the individual’s cultural background. • Availability of resource people (eg, family, friends, coworkers, and employee assistance programs) who can positively affect outcome Telephonic Intervention Our telephonic workers’ compensation case management (CM) unit at The Hartford recently received full URAC accreditation. Nurse case managers must be aware of and comply with the URAC standards to obtain this accreditation. One of these standards specifically says the CM organization shall establish policies and procedures to protect the safety of clients and case managers. When this policy was introduced to our staff, we discovered an opportunity to help our telephonic nurse case managers become more comfortable speaking with injured workers. Specifically, this training will be useful if they believe the worker is in crisis and safety has become an issue. TCM 54
March/April 2002
The most common safety issues involve situations in which the worker either speaks about doing harm to him- or herself or others. In these situations, the case manager must gather as much information as possible about the individual’s intent and surrounding circumstances. Only when this information is known can urgency be evaluated and a course of action be determined. When an injured worker calls in crisis, the case manager must be able to use basic communication skills. If the injured worker has no readily available family or community supports, a call to the case manager can be invaluable. The role of the case manager in this situation is to listen, support the worker, and provide information and referrals as needed. The caller in crisis may not be able to logically reason out a plan to address the problem for which he is calling. Wilson and Kneisl5 group callers into one of four categories: crisis calls, ventilation calls, combination calls, or informationonly calls. Ventilation calls may address issues related to anger about treatment, lack of progress, continued pain management issues, return-to-work issues, and frustrations in navigating the health care and worker’s compensation systems. These calls are best managed by empathetic listening and information sharing. This approach may sound simplistic, but dealing with the anger that comes from frustration can be very challenging, especially if the injured worker has learned to get what he wants by being demanding, aggressive, cursing, and threatening. The key to managing these calls is to remember that the injured worker is reacting to not getting his needs met in the only way he knows how to react. A common mistake that case managers make is taking offense to the anger as if they were responsible for it in some way. It is not necessary to defend the employer, company, physician, or other individuals. Instead, they should listen and work toward helping the individual cool off enough to think clearly and look at ways he can solve the problem. For a true crisis situation, communication needs to be more direct and requires more specific management.
General rules include the following: • Keep your voice and messages to the injured worker calm. Sounding upset or worried can escalate the situation. • Determine if the injured worker is in a situation in which he may harm himself or others. Ask questions about this simply and clearly, “Are you saying that you plan to injure yourself or your employer?” • Use active listening techniques, such as open-ended questions, “Tell me what you are thinking of doing.” Then paraphrase the worker’s answer to be sure you understand the message. Identify feelings of anger, frustration, depression, and such that may not have been expressed. • Problem-solve with the individual. If immediate action is needed, have a coworker assist you by getting help to the injured worker (ie, notifying police or emergency services) or alerting appropriate management staff according to policy. • Talk with the worker about a safety plan. Much has been written about developing a contract for safety, and realistically, it does work sometimes.6 Talk about specific solutions. Get the injured worker to make a written list of possible actions he could take, people to call, places to go for help, etc. Give information and assistance that may be available. The communication and actions taken during these calls must be documented in the injured worker’s file. Remember, legally speaking, if it was not documented, it was not done. The nurse may want to check over documentation or ask a supervisor for assistance in ensuring that the report is factual, concise, and appropriate. The nurse case manager should realize that many employers may have access to information regarding their employees’ worker compensation injuries and, in some cases, even the file containing this information. This access should be taken into account along with privacy laws when documenting interactions with patients. For example, the injured worker may speak of nonwork-related issues and perhaps
other issues related to his workers’ comp injury. It may be best for you to refer directly to the work-related injury issues and then address the injured worker as also having mentioned personal issues that he is upset over.
Follow-up also allows the case manager to determine if any further action is needed. This follow up also can help strengthen the case manager’s relationship with the injured worker because it reinforces the advocate role.
After you have handled the situation, debriefing with a colleague or supervisor is always a good idea. Give yourself an opportunity to go back over the situation. This review will serve both to decrease the stress that will accompany handling these calls and help you look at things you may want to do differently the next time you get a call from a worker in crisis.
After all is said and done, it is important for the case manager to realize that the injured worker is responsible for his own decisions. However, by following company policies based on URAC standards as we do at The Hartford, our nurse case managers can believe they have dealt with what can be difficult situations to the best of their professional abilities. ❑
The final step in this process is to follow up with the injured worker the day after your communication or at the time you indicated you would do so based on the urgency of the situation. This follow-up is important so that the nurse case manager may determine if the injured worker has obtained the assistance or taken the actions that he indicated he would.
References 1. American heritage dictionary. 2nd ed. Boston: Houghton Mifflin; 1982. 2. Caplan G. Principles of preventive psychiatry. New York: Basic Books; 1964.
3. Murray R, Huelskoletter M. Psychiatric/mental health nursing: giving emotional care. Norwalk: Appleton & Lange; 1991. 4. Lassiter SM. Multicultural clients. A professional handbook for health care providers and social workers. New York: Greenwood Press; 1995. 5. Wilson H, Kneisl C. Psychiatric nursing. Menlo Park: Addison-Wesley; 1996. 6. Egan M. Contracting for safety: a concept analysis. Crisis 1997;18(1):2. Janet R. Appelhans, RN, BS, CCM, and Sylvia Kupferer, RN, MS, NCM, are case managers for The Hartford in Aurora, Ill. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/123060 doi:10.1067/mcm.2002.123060
March/April 2002
TCM 55