The Internal Dialogue of Advocacy
by Kathy Craig, MS, RN, CCM

Famous for mighty cross winds that make it a training site for Olympic sailors, the Thousand Islands region of Canada became my training ground for staying the course. Case management (CM) international began in 2005.

Canada CM wasn’t like the state-of-the-art CM I practiced at the click of an electronic button in the United States. The single-payer system included surgery and service waitlists, paper-based records written longhand. Between conventional methods and home visits, I either consulted a procedure manual or road map routinely.

Events connected invisibly. Butterfly wings that didn’t flap a financial world away sucked the wind from our coffers. A federal budget fails, crashes the country’s government and an aged woman forfeits an aide for a weekly wash. Hands on ropes, I tacked streams of subtle connection.

January 2006 launched a year-long assignment in oncology. Judging by the chart marks, I was moving steadily forward, navigating CM in a new country.

Then I returned in December from a week away. There, set apart on a cluttered desktop, lay the solitary envelope that seemed rung with a solemn halo. Its gravity drew me. I slid the letter from its sliced-open envelope. A distraught family member lamented upset over a client’s care in her last weeks of life in February. Ten months was a lifetime ago, for both of us.

Suddenly, security slipped its moorings. Everything looked foreign.

I was thrown off-kilter by the callous way management left the complaint to be found like mold. It wasn’t “Welcome back,” pat-on-the-back. Was it a cold water slap? Management critiqued decisions I made months and moments ago. One client’s needs I assessed were under heavy scrutiny. Why did I ask for these services? Wouldn’t the client be safe with less? Amend choices. Explain reasoning.

Wave-tossed thoughts sloshed against ragged emotions. How poorly had I assessed that client? Client interviews were a strong suit. Wrong again? Field nurses said I uncovered surprising details. Ruse or true? I developed care plans well and implemented appropriate services. Skill or delusion? I gathered facts and determined risks. Or, did I?

I needed to decide what to do for the client taking the brunt of my fallibilities. Would I stand or fold? Even colleagues’ support couldn’t rescue me from trashing and wavering. My thinking was so clouded I couldn’t decide if I was of sound mind or sounding mindless.

I went home Tuesday night, sat down, and re-ran the process: assess, examine, document, match to best resources. Check. The picture of the client’s supports, symptoms and problems was accurate. Check. What I advocated for was proper and reasonable. Check. The internal compass was righted. Well-deep strength surfaced with a word: persevere.

With steadfast calm, I approached the supervisor on Wednesday and advocated for my client once more. Yes, send relief.

By adhering to the enduring content of CM, storm winds were quelled. When the internal dialogue of conscience matched the guiding process of CM, safe harbor was reached in the great waters of Lake Ontario.