Donna Strickland Blog

Saving Your Career in the 21st Century

by Donna Strickland and O. C. O’Connell

This article addresses the fundamental and dramatic changes that case managers must undergo internally to keep pace with a rapidly and radically changing work environment as we move into the next millennium The work paradigm is transforming from a model of well-defined job descriptions and clearly articulated career ladders within organizations to a fluid workforce in which individuals must now view themselves as a mobile portfolio of skills responding to particular needs within organizations ‘Hence, case managers must retool their thinking, unlearn old beliefs that hinder success, and learn to manage their careers as micro-businesses within their organizations. This new model is founded on self-responsibility, entrepreneurial aptitude, vision and personal empowerment. Taking charge of one’s career and consciously directing it is a dramatic departure from the norm for most individuals. There is a widely held tendency in our culture to define ourselves by our job titles. This is both an antiquated and myopic view that needs to be discarded to succeed in the future. Health care is a dynamic and evolving industry that requires forward-thinking, flexible, solutions-oriented people. The time is upon case managers to undergo a personal renaissance to artfully position themselves for success in the next millennium.

You check your e-mail from your home computer in the evening after the kids are tucked in to bed. You leave a colleague a voice mail message long after the traditional close of business giving a pre-authorization code for a surgical procedure. You stop by your desk on a Saturday morning to review a few charts that you didn’t get to because of all the home care arrangements you had to make for patients discharged on Friday. You are paged in the middle of lunch about a patient who’s developed complications. Work happens anywhere, anytime!

The landscape of health care has changed dramatically during this decade. Look around and you see that in the 1980s and early ’90s the consumption of health care services by the average American was largely dictated by that person’s physician. The physician enjoyed an exalted status, monopolizing control over the patient’s course of treatment, making decisions about the location of that care (inpatient vs. outpatient), even selecting ancillary providers, and largely directing the flow of both technological and monetary resources toward that care. The role of the nurse case manager was limited and even obscure in some regions of the country.

You know firsthand that the delivery and consumption of health care has become a richly colored, multifaceted, complex tapestry integrating payers, providers and consumers. Health care today is replete with a myriad of choices that patients, who have become clients, and their families, must make in concert with the payer and the provider. The nurse case manager now provides a fundamental link among these entities to ensure cohesive care while containing costs.

Patients enter and leave the hospital under much greater duress. Three years ago who would have believed that the standard length of stay for a person undergoing a total hip replacement would be 4-5 days! The medical community would have been horrified to send a patient home before twice that length of stay. However, it is now expected that the patient and/or the patient’s family is responsible for participating in the care and recovery to wellness. No longer is there a paternalistic health care system that assumes the process like a monolithic big brother while the patient passively follows directions and “waits for wellness.’ It is incumbent upon the patient, the client, to actively assist in her/his own care and recovery.

It is only natural that the evolution which has gripped the health care industry these past 10 years radically altering the consumer’s interaction with that system would eventually lead to dramatic innovations in the careers of health care professionals. The time for a new paradigm of career management is upon us. The same proactive participatory and dynamic involvement required of consumers is now essential for case managers.

There is a movement afoot on a global level, a universal energy gathering momentum, that we each take greater responsibility for our lives, our happiness, and our development. Along with the education of the health care consumer, this same level of accountability and personal responsibility can be seen in the workings of large corporations which are striving to create entrepreneurial divisions (Saturn, Microsoft, NASA) with work teams who have the authority to make significant operational decisions. Likewise, there is a growing trend toward more personal spirituality which is imbued with a philosophy of partnership with the Divine in which we each have a responsibility to walk as a person of faith, fully participating in life and working in concert with the mystical nature of life. Some forward thinking health care systems are integrating services along the entire continuum of care such that the various service lines from inpatient hospital units to home care, outpatient and hospice care articulate with each other. There is seamless delivery and management of the patient’s comprehensive needs. In this arena the traditional case management function within a department has been transformed across services and supervisors.

The convergence of all these factors–technological, spiritual, financial, and entrepreneurial results in opportunities for those who have the courage and the insight to create a new vision for themselves. No longer do you work in an era of guaranteed employment. Those days when a nurse started out working the graveyard shift in a hospital and gradually moved to the day shift as she gained seniority are long gone. So too are the days in which nursing was defined in a fairly narrow sense, differentiated primarily by whether you worked in Pediatrics, ICU, OB, med-surg, etc. Nursing has exploded into a dynamic, complex field with countless possibilities for the clinician, the executive, the case manager, the academician, the researcher, and most significantly, the entrepreneur.

It is no longer prudent to think of yourself as an employee of a certain entity, carrying a specific title. The new millennium isn’t about job security; it’s about employability. In order to maximize your employability you need to undergo a fundamental shift in which you abandon the notion of being an employee and embrace the idea that you are your own CEO (Bridges, 1997). You need to see yourself as a talented, well credentialed individual with an extensive portfolio of skills, resources and experiences. And, you need to market yourself as such.

This is no small task! This can be intimidating for those of you who have never really managed your career, except for applying for job postings within your organization. This is the point where you could panic to the degree that you become immobilized. Don’t do it! Many new ideas, skills, and projects can seem overwhelming from afar but if you view them as a series of small steps, they are really quite manageable.

The author of The Fifth Discipline beautifully articulates a principle that he refers to as personal mastery. He defines personal mastery as a discipline of lifelong personal growth and development (Senge, 1990). It is an activity fully integrated in our lives, making our lives a creative process always unfolding. There are two underlying tenets of personal mastery that provide guidance and direction. First, there is focused attention on what is really important to us, so we remain committed and conscious about our chosen path. Second, we continually try to see the current reality more accurately. It is in identifying our present position accurately that we can navigate a course to our ultimate destination.

Additionally, persons with a high level of personal mastery share some common characteristics. They have a sense of vision and purpose about themselves and their work. They are inquisitive, confident and see themselves as intimately connected to others and as part of something larger. They hold deep values and have the capacity for delayed gratification, which allows them to strive for meaningful goals and live in a state of creative tension. Moreover, people who follow a path of personal mastery. enjoy high levels of fulfillment and happiness (Senge, 1990).

The question becomes, how can you walk a path of personal mastery, committed to your own truth and success? A friend of mine called recently feeling a little out of sorts. She told me that one of her colleagues resigned her position as the supervisor over the case management staff to do health care consulting. My friend said she was jealous of her colleague and the challenges and opportunities inherent in her new occupation. She bemoaned her own circumstances, wishing she could do something so exciting and independent. She explained that she could never make such a change because her family needed her income, she lacked the credentials although she had plenty of experience, and it would be too painful to give up 4 weeks of paid time off. My friend perceives that she is stuck, trapped in her current position and fearful that she could get laid off if the organization undergoes further consolidation. My friend is right–both her fear and her limited vision ensnare her. The result is that she finds herself living in a state of inertia that she is unable to overcome.

Contrary to my friend’s belief, she is not a victim of circumstances, mergers or the rapidly changing health care environment. She would like to believe that others–the system, her supervisor, her family–hold her hostage. Actually she is her own hostage with the ability to free herself whenever she chooses (Grudermeyer, 1995). She will be emancipated the moment she holds herself accountable for her own happiness and career choices. In order to accomplish this she must develop a deeper relationship with herself founded on truth. Only then can she create a vision for herself and live purposefully, always working toward her ultimate goals.

There are at least two critical attributes that need to be nurtured and developed to live a fulfilled and committed life. The first is an extremely powerful thought pattern that influences success, called self-efficacy. Self-efficacy is the belief that you can exert control over specific events in your life (Kabat-Zinn, 1991). The belief that you can succeed influences the course of action you choose, the amount of effort you put forth to attain the goal, and the amount of stress you experience in the process. For instance, suppose that there is a patient who has been hospitalized for congestive heart failure whom you want to discharge and allow home care to provide skilled nursing and physical therapy services. The patient has voiced reluctance about going home and the physician is known for keeping his patients in the hospital as long as possible. You believe fully that discharging the patient with home care services is appropriate and reasonable. How hard will you lobby to discharge the patient? Will you attempt to persuade the physician? Will you meet with the patient and the family to allay their fears and deal with their concerns? Maybe you’ll seek out the physician right away and try to resolve the situation or perhaps you’ll put it aside until after lunch. You’re under budget overall, so maybe you’ll let this slide…

Ultimately, the strategy you choose to deal with this case will hinge on a number of factors. The degree of effort you put forth will depend greatly on whether you believe you can approach the physician and convince him of your point of view, whether you have allies, including your supervisor who will support you, whether there is any backlash for aggressively pursuing your goal, etc. Without necessarily even realizing it, the decision you make is determined by the degree of self-efficacy you experience in that particular situation. If you were successful in getting the patient discharged your sense of self-efficacy will increase and will continue to increase every time you succeed at your chosen endeavors. Moreover, self-efficacy enhances physical health as well as emotional and psychological well-being. Studies have shown that when people with low self-efficacy undergo training to develop mastery experiences, their self-confidence blossoms as does their ability to control facets of their lives which previously seemed impossible to handle (Kabat-Zinn, 1991).

People who have a strong sense of self-efficacy also characteristically possess a great deal of psychological hardiness. Dr. Suzanna Kobasa of the City University of New York and Dr. Aaron Antonousky, a medical sociologist in Israel, have conducted significant research in this area. Like self-efficacy, stress hardiness involves holding a particular view of oneself and of the world. Individuals typically have high levels of three psychological attributes: control, commitment and challenge (Kabat-Zinn 1991). People with a strong sense of control believe that they can influence their circumstances. Those high in commitment tend to be fully present and engaged in their work, putting forth their very best efforts. Lastly, folks high in challenge see change as a natural part of life, offering opportunities for personal growth.

There are numerous things one can do to increase stress hardiness. Dr. Kobasa suggests that the best way to enhance this trait is to honestly assess your own life, the direction in which you are headed, and see how your life could be enriched by specific choices and changes you could make, respectively, to the areas of control, commitment and challenge. Improving self-efficacy and hardiness goes a long way toward the creation of a self-determined career path.

Every autumn my sister Ginger, my sister-in-law, another friend and I hike a “fourteener” in my home state of Colorado. This has been a fall ritual among us for as long as anyone can remember. This past October we were hiking in the Collegiate Peaks on a sparkling morning under a brilliant blue sky. We had been walking for a couple of hours single file with my sister-in-law and friend ahead and my sister behind. I was aware of the steady cadence of Ginger’s steps providing a measure of companionship as we labored without speaking. Then, without pre amble, the sound of my sister’s footfall against the rocky earth fell silent. I turned to see that she had stepped and was leaning heavily against a boulder. I walked back to her and she burst into tears that she couldn’t do it. This year, this mountain was too much. She apologized repeatedly that she just couldn’t go on. She was carrying 20 extra pounds, struggling intensely. More painful to witness than her battle for air was her shame about her struggle and perceived failure. She thought she was the only one of the four of us working hard, and, as a result, she felt alienated and disconnected. She felt that she was somehow less than the rest of us. The fact was we were all struggling, and it was only because I was in front of her that she could not see the strain on my face or hear the effort in my breathing.

My sister was prepared to abandon our goal, to lower her vision because of her physical and emotional discomfort in her present reality. She could not hold the creative tension because the distance between her current location and the top of the mountain seemed too great. Ginger wanted to do what most of us want to do when we are tired and spent and the mountain still looms interminably ahead: quit. That’s the thing about mountains though–they’re tough to climb. Whether your mountain is metaphorical or physical, when you decide to climb it you’ll sweat, you’ll get dirty; you’ll need every ounce of energy you can muster. If climbing a mountain were a walk in the park, almost everyone would do it frequently. When Ginger and I sat down on the boulder and talked, she told me that she believed that I was not having any difficulty hiking up this imposing mountain. The reason she thought that was simply because I was in front of her. Once she realized that I had been wishing that a canister of oxygen would miraculously drop from the heavens we had a good laugh about how old and overweight we both felt. Ginger was able to find a renewed sense of determination and commitment to the goal. We then hauled it swiftly right on up to the top!

Now, it seems like every time that we talk the conversation finds its way back to our climbing adventure on that mountain. The bond between us has deepened even further as a result of that experience. The gifts the mountain offered us were an enduring sense of accomplishment and connection to each other.

Staying connected to yourself and to others, being part of a community, gives purpose and meshing to life. It is in deepening the relationship with yourself and others that the self is affirmed and valued, thus creating an ongoing cycle of connectedness, effort and feedback that promotes and strengthens self-efficacy and psychological hardiness (Kabat-Zinn, 1991). Additionally, there are some other practical steps to saving your life and career:

  1. Believe in yourself Hold on to your hopes and dreams with all your might. Run the race, climb the mountain, reach for the stars. Believe in yourself one moment at a time. Don’t waste time worrying about the big picture; just believe for this minute, right now, right here. You can do it! Show the same faith in yourself that you do in a trusted colleague. In short, don’t quit before you’ve even begun.
  2. Recognize the realities. The era of “This is the way we’ve always done it” is over. Old paradigms are crashing everywhere; don’t be lulled into believing that change is going to slide by and miss your organization. You need to understand and deal with the ways in which work is going to change. It will be more entrepreneurial and creative than ever before. One of the most difficult aspects of organizational change is feeling that everything is out of your control, that you’re being swept away in the current. Not so! You have choices about how you respond, how you learn, how you deal with new events and philosophies. You can control some elements, and, the best way to do that is to become involved in the change process. Involvement does not take away all the difficulties, it makes you a creative participant in the process instead of a passive victim.
  3. Identify what you do best. Recognize and claim your talent, experience and strengths and then augment these skills by gaining further credentials in your field. A set of impressive credentials valued in your field will open new doors, enhance your status and increase your marketability.
  4. Accept unpredictability. Your job is not an entitlement. Rethink your strengths and your abilities. There may be other opportunities for you to apply your talents: the ability to organize and set priorities, multitasking skills and initiative could help you succeed in your own business. You are not where you work. In the professional arena learn to think of yourself as a portfolio of skills that can go to multiple job sites.
  5. Pursue your passion. You may be well credentialed in an area that isn’t reflective of your true aspirations. Align your heart with your work and hardiness, self-efficacy and personal mastery will begin to unfold.
  6. Embrace lifelong learning. Read a book. Take a course. Attend a seminar. Promise yourself that you’ll learn one new thing every day. Observe a kindergarten class and you’ll learn things you never knew you didn’t know! The world is new each day; innovation and change are the highways of our lives. Without ongoing education your skills will be antiquated and your employability diminished.
  7. Resurrect your resiliency. You will be tried and tested. The road to excellence is littered with teachable moments, good ideas gone awry and all manner of surprises. Learn to bounce back from a disappointment –who knows what success will rise from a seeming failure!
  8. Go exploring. Don’t stay stuck in the status quo out of fear. Practice letting go of the familiar long enough to allow yourself a new experience. Your life is a trek of wonder and discovery —create something magical for yourself.
  9. Laugh along the way. Maintaining a sense of humor is a fundamental survival skill; don’t leave home without it!
  10. Network, network, network. Build relationships. Join forces with other colleagues. Get active in your local chapter of a professional organization. Volunteer to work on a task force or committee responsible for implementing changes in the system. Step up. Take a stand. Go out on a limb. Let people know that you’re interested in being a part of the solution. Often, new leader-ship emerges in times of transition that may lead to more opportunities. You may have the chance to demonstrate capabilities that are valuable to the organization, but for which you didn’t have a forum for which to showcase them previously; now’s your chance!
  11. Follow a spiritual path. Devote time to the spirituality of your choice. Belief in a particular religious or spiritual tradition will give you inspiration and deepen your sense of commitment and belonging in the world. Let your soul routinely commune with the Divine, feeling the ebb and flow of life’s mystery without trying to will your way to your destination or abdicate responsibility for your life to your God.

No one else deserves success and fulfillment more than you do. You are entitled to a career and a life that is rich in joy and financial abundance. There is more than enough for all of us. All that is required is that we each do our part, claim responsibility for our future and act accordingly.


  1. Bridges, W. (1997). Creating you & co. Reading, MA: Addison-Wesley. Volume 7, Number 2 · Summer 1998
  2. Grudermeyer, D., & R., & Patrick, L. N. (1995). Sensible self-help: The first road map for the healing journey. Del Mar, CA: Willingness Work Press
  3. Kabat-Ziun, J. (1991). Full catastrophe living (pp. 199-221). New York: Bantam Doubleday Dell Publishing Group, Inc. Senge, P. (1990). The fifth discipline (pp. 139-173). New York: Doubleday.

Donna Strickland, MS, RN, CS, is President and Queen of Everything, The People Connection, Ltd. O.C. O’Connell, MBA, is a freelance writer.

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