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  1. Craig, Kathy MS, RN, CCM
  2. Banja, John D. PhD


Objectives: Case managers will occasionally witness colleagues from their own or other healthcare disciplines providing care in ways that frankly deviate from or violate standards of care, rules, regulations, policies, and procedures. This article will discuss the case manager's ethical obligation to speak up in such instances as well as list strategies illustrated in this article by a three-color flag system that classifies poor, better, and best responses to ethically challenging situations.


Primary practice settings: All case management work environments.


Findings/Conclusions: When health professionals practice in ways that deviate from established policies, procedures, rules, regulations, and standards of care, they jeopardize the safety and welfare of their clients and, often, their employing institutions. Although speaking up is often difficult due to fears of retaliation or an organizational nonresponse, the fundamental ethical obligation of case managers is to protect and further their client's health and welfare rather than their professional self-interests. Consequently, the ethically conscientious case manager will pursue strategies whereby weaknesses or latent hazards that might compromise a client's care can be remediated.


Implications for case management practice: Because they practice in the midst of multidisciplinary care, case managers have a marked opportunity to witness any number of practice standards being ignored or violated. Case managers need to cultivate a heightened moral awareness and response to such situations, especially when deviations from standards of care have become routine or "normalized." Critical elements in speaking up include cultivating a method to discern the moral perils of remaining silent, learning communication techniques to conduct emotionally challenging conversations, and building organizational leadership that recognizes the value of speaking up and supports safe harbors for employees who speak up appropriately.