1. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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There are so many issues we can be reminded of this time of year: being grateful for what is in your life (and thankful for the myriad of things that are not in your life); knowing what is important, and not stressing about the small stuff; realizing how much good you do in the world and taking care of yourself-to name a few. Here is a reminder we have spoken about before: it may preserve your sanity in times of stress.


Case managers have more than their fair share of conflict. Dealing with patients, families, healthcare providers of every type, and insurance companies are enough to give us a pause. However, particularly this time of year, we are also dealing with our own family dynamics. Auntie Em is not just baking cookies; she is also heating up history that may be better left on a cooling rack in the past!!


This journal has had three "Professional Development" departments by the group that teaches Crucial Conversations. This is not just another "positive mental attitude" technique; it is a set of skills to deal with situations when the stakes are high and the emotions are simmering. This editorial will talk about one Crucial Conversations technique. What is this technique that will help preserve my sanity during stressful times (you ask)?


The technique is merely asking an explicit question at a specific time. That is, when a conversation starts to turn "crucial," begin by asking, "Why would a reasonable, rational, and decent person" say this, push my buttons in front of others, bring that up (again), etc.? Well, certainly the developers of Crucial Conversations know that not everyone is reasonable and rationale (and this person who is annoying me is not!!). This is true.


But, dear reader, do not miss the point. The point is that by asking the prime question ("Why would a reasonable, rational person do or say this?"), you are opening up possibilities that may turn the situation from one of escalation to one that promotes mutual understanding. Crucial Conversations determines that the "fundamental attribution error" is the automatic assumption we often make that the other person's motives are bad. This can happen when someone says or does something we think is harmful or threatening. We immediately attribute bad motive-we tell ourselves a "villain" story: they are evil or selfish; they do bad things because they enjoy it (McMillan, 2007).


Therefore, this question is a technique to challenge your villain story and avoid making the fundamental attribution error. This is not about burying your head in the sand, being in "denial," or playing Pollyanna; it is about opening opportunities. Here are some possibilities the simple question can elicit; consider this sequence of thought change:


1. First, we are not automatically assuming the very "worst"-that because someone seems mean and nasty, they are not intentionally out to make us look bad or foolish.


2. This may change our basic emotion of the moment from anger to curiosity, or maybe even concern.



This change of attitude is important. Think of two diverging roads:


a. The road you would go down feeling belittled and angry. Anger is often manifested by violence; others show their anger by becoming silent (crucial conversations calls this going into "silence or violence.") (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005).


b. The road you would go down if you felt curious or concerned. When in a condition of curiosity, we are more likely to ask questions and engage in dialogue. "As we talk over the problem and gather more information, we're in a better position to ascertain the other person's motive and intent" (McMillan, 2007, p. 1).



Suppose we found out that the other person's motives were not meant to "slice and dice" you (although they may have been insensitive or inappropriate). This puts you in a good position to solve the problem together (perhaps in private, at a better time). Or, suppose you discovered that the motive was meant to hurt or disparage you. At least you are now thinking with your head, rather than your adrenal glands. This allows you to act professionally and rationally and decide on the next move. It is a wonderful place to be in, considering the alternatives: public or professional suicide or family feud.


A little scenario without "the question":


Doctor: I got a letter from the hospital saying that they didn't get paid because Ms. SweetPea with chest pain should have been in Observation Status and not admitted.


You: Are you telling me that I am the one who caused this? (Said in a very sarcastic tone of voice.)


Doctor: You're the Cardiac Case Manager!!


You: Well, maybe if you would listen to me once in a while, you would see I have been trying to tell you the difference between Observation and Inpatient Status for over a year!!


Try it again with "the question":


Doctor: I got a letter from the hospital saying that they didn't get paid because Ms. SweetPea with chest pain should have been in Observation Status and not admitted.


You: (Thought Bubble: Why would a reasonable, rational, doctor SAY something like that?) Did you feel as though you were being blamed for the hospital not being paid? (Note that you were not sarcastic or defensive; you were curious.)


Doctor: I did. I felt bad-but the rules, regulations, and criteria are so darned confusing-not to mention that doctors are being so scrutinized that it is hard to feel we have time to take care of patients' clinical needs.


You: I think I can help with the initial problem. We have something called the "Case Management Protocol." It allows you to concentrate on the clinical issues, while the case manager helps you to determine the correct patient status. If you are interested, we can choose a convenient time to talk about this process-and hopefully, you will not see another one of those letters. We can use Ms. SweetPea's case as a study.


Doctor: If this is true, it would help a lot.



Try this little "question technique" for a month or two. Try it on your spouse, your adolescent child, your boss, your patient's significant other, and even yourself on occasion. Look for the "shift" in the conversation; sometimes it is almost miraculous. Have a wonderful, miraculous, and safe holiday season.




McMillan, R. (2007, July 4). Dealing with the unreasonable and irrational. Crucial Skills Newsletter, 5(27), 102. [Context Link]


Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence kills: The seven crucial conversations for healthcare. Retrieved from$file/SilenceKills.pdf[Context Link]

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