Expectations	Rationale
__________________________	_________________________
__________________________	_________________________
__________________________	_________________________

The exercise in the Critical Thinking: Personal Expectations box should give you some insights into why a nurse must have assertiveness. At the end of this chapter you are encouraged to do this exercise again. Evaluate any changes in your expectations.

Verbal, nonverbal, and affective communication translates into three major behavior patterns. You will hear, see, and feel the message acted out. The most effective communication style is open and honest. It promotes positive relationships and a healthy sense of self. Ineffective communication or behavior is hurtful. It blames, attacks, or denies and is harmful to the self as well.

An assertive style separates the person from the issue. Most important, you speak out of choice. An emotional hook catches you when you use either an aggressive or a nonassertive (passive) style of communication. Both types of responses are automatic responses. You no longer respond from choice. The three major behavior styles are nonassertive (passive), aggressive, and assertive.

Nonassertive (passive) behavior

Nonassertive (passive), fear-based behavior is an emotionally dishonest, self-defeating type of behavior. Nonassertive nurses attempt to look the other way, avoid conflict, and take what seems to be the easiest way out; they are never full participants on the nursing team. Nonassertive individuals do not express feelings, needs, and ideas when their rights are infringed on, deliberately or accidentally. There may be a lack of eye contact, swaying and shifting from one foot to the other, and whining and hesitancy when speaking. The overall message is “I do not count. You count.” This personal pattern of behavior is reflected in their nursing as well. Consequently, they are unable to recognize and meet patient needs. Some examples of nonassertive behavior, with the type of behavior in parentheses, that were observed in one nurse follow:

• Tells another nurse how “stupid” the doctor is for ordering a certain type of treatment (indirect, nonassertive behavior).

• Limits contact with a patient he or she is uncomfortable with to required care only (indirect nonassertive behavior).

• Routinely tells patients who ask questions about their illness, test, medications, or treatment to “ask the doctor” or “ask the RN.” Although this answer is advisable some of the time, it certainly is a form of brush-off. Part of nursing responsibility is to seek answers for the patient (takes the easy way out).

• Experiences inability to continue with a necessary, uncomfortable treatment ordered for the patient (interprets patient’s expression of discomfort personally: “The patient will not like me if I do this”).

• May assume, without checking, that the patient wants to skip daily personal care when a visitor drops in (avoids conflict).

• Experiences a feeling of being “devastated” when a patient, doctor, nurse, or other staff person criticizes his or her work (interprets criticism of work as criticism of self).

• Responds to patient’s questions about own personal life and that of other staff (afraid of not being liked).

• Patient asks nurse to pick up some personal items on the way home. Nurse frowns but agrees to do so (communicates real message nonverbally).

• Becomes angry with the team leader and drops hints to others about own feelings (communicates real message indirectly).

• When asked by another nurse to assist with the care of assigned patients, responds by saying, “Well, uh, I guess I could,” although already too busy (hesitate, repressing own wishes).

• Needs help with assignment but says nothing (refrains from expressing own needs).

• After making an error, overexplains and overapologizes (is unaware of the right to make a mistake; should take responsibility for it, learn from the error, and go on).

• Plans on finding a new job because of fear of approaching supervisor to tell own side of what has happened (avoids conflict).

• When “chewed out” by the doctor in front of a patient, gets angry but says nothing (refrains from expressing own opinion—internalizes anger).

Try This

Nonassertive Behavior

Identify nonassertive behaviors in which you have been involved. Describe how each behavior worked or did not work for you.

By not taking risks and not being honest, nonassertive nurses typically feel hurt, misunderstood, anxious, and disappointed and often feel angry and resentful later. Because they do not allow their needs to be known, they are the ones who lose out.

Critical Thinking

Nonassertive Behavior

Develop a plan for change for each one of the nonassertive behaviors that you identified as having unsatisfactory outcomes.

Aggressive behavior

Outspoken people are often automatically considered assertive, when in reality their lack of consideration for others may be a sign of aggressive behavior. Aggressive (anger-based) behavior violates the rights of others. It is an attack on the person rather than on the person’s behavior. The purpose of aggressive behavior is to dominate or put the other person down. This behavior, while expressive, is self-defeating because it quickly distances the aggressor from other staff and patients. Examples of aggressive body language include leaning forward with glaring eyes; pointing a finger at a person to whom you are speaking; shouting; clenching fists; putting hands on hips; and shaking the head. The overall message is “You do not count. I count.” The following examples show how aggressive behavior can be recognized. An explanation of the rationale is included in parentheses.

• You have asked to go to a workshop, and the supervisor says, “Why should you go? Everyone else has worked here longer than you have” (attempts to make you feel guilty for making a request).

• Another nurse points out your error in front of other staff and adds, “Where did you say you graduated from?” (attempts to humiliate as a way of controlling).

• A peer approaches you with a problem. You don’t want to listen and say, “If it isn’t one thing, it’s another for you. Why don’t you get your act together?” (disregards others’ feelings).

• A new rule is instituted without requesting input from or informing those it will involve. You protest but are told, “That’s tough; this is the way it’s going to be from now on” (disregards others’ feelings and rights).

• The patient has had his call light on frequently throughout the morning. You walk in and say, “I have had it. You have had your light on continuously for nothing all morning. Do not put your light on again unless you are dying, or I will take it away” (hostile overreaction out of proportion to the issue at hand).

• You attempted to express your feelings to a peer about his or her behavior toward you. Today the peer greets you with an icy stare when you say hello (hostile overreaction).

• The patient tells you, “I thought this was a pretty good hospital, but none of you seem to know what you are doing” (sarcastic, hostile).

• You push yourself in front of others in the cafeteria line (rudeness).

• You ask the nurse manager a question. Instead of answering, he just stares at you with lips curled slightly upward (attempt to make you uncomfortable, a put-down).

Try This

Aggressive Behavior

Circle the aggressive behaviors in the previous example that are similar to behaviors you have experienced.

Critical Thinking

Aggressive Behavior

Develop a plan for dealing with the aggressive behaviors you identified in the previous learning exercise.

Aggressive behavior certainly is a way of saying what you mean at the moment, and it does produce temporary relief from anxiety. The feeling, however, does not last. Very often the aggressive person is left with residual angry feelings that simmer until the next stressful situation or person comes along. It is interesting to note that sometimes an aggressive person was once passive and made a decision that “no one will ever step on me again.” However, instead of practicing assertiveness, such a person practiced and became involved in another form of destructive, self-defeating behavior. Aggressive nurses, like nonaggressive nurses, are unable to function as true advocates for the patient because they are too busy taking care of what they perceive to be their personal needs.

Assertive behavior

Assertiveness is another name for “honesty”—that is, it is a way to live the truth from your innermost being and to express this truth in thought, word, and deed. The concept seems simple enough, but it is another thing to be truthful all the time. According to Webster’s Dictionary, assertiveness means “taking a positive stand, being confident in your statement, or being positive in a persistent way.” You, the nurse, work in a setting that requires speaking frankly and openly to others in such a way that their rights are not violated. Assertiveness is a tool, not a weapon. As with any new behavior (or skill), becoming truly assertive will take practice and time. Avoid being harsh with yourself or giving up just because old behaviors emerge when you are under pressure. Resolve to try again until assertive behavior is integrated as a part of your being. Although it is not the nurse’s right to hurt others deliberately, it is unrealistic to be inhibited to the point of never hurting anyone. Some people are hurt because they are unreasonably sensitive, and some people use their sensitivity to manipulate others. Assertiveness is not only what you say but how you say it. Examples of assertive body language include standing straight, steady, and directly facing the people to whom you are speaking while maintaining eye contact; speaking in a clear voice, loud enough so the people to whom you are speaking can hear you; and speaking fluently without hesitation and with assurance and confidence.

Nurses have a right to express their own thoughts and feelings. To do otherwise would be insincere. It would also deny patients and other staff the opportunity to learn to deal with their feelings. Assertiveness, then, is a way of expressing oneself without insulting others. It communicates respect for the other person, although not necessarily for the other person’s behavior. The overall message is “I count, and you count, too.” Being assertive does not guarantee that you will get your way. What it does guarantee is that you will experience a sense of being in control of your emotions and your responses. Win or lose, you gave it your best shot. The real bonus is freedom from residual feelings of fear and anger. Later in this chapter, we will deal with exceptions when you are faced with a potentially violent situation.

The following examples, with the rationale in parentheses, are expressions of assertive behavior. As an assertive nurse, you claim responsibility for your own feelings, thoughts, and actions. Using “I” in your statements shows acceptance of responsibility for your thinking, feeling, and doing.

• The doctor orders a medication or treatment that seems inappropriate. You request to talk to the doctor privately and ask about expected outcomes. You present any new information you have that may potentially affect the decision to continue with the order (direct statement of information).

• The patient has been giving you a bad time. Pulling up a chair and sitting down, you say, “Mr. Smith, I would be interested in knowing what is going on with you. I have noticed that whatever I do, you are critical of my work.” Then you listen attentively and with understanding (comprehension) and respond nondefensively (direct statement of feelings; does not interpret patient’s criticism as a personal attack).

• When the patient requests information you are unfamiliar with regarding the illness and treatment, you say, “I do not know, but I will find out for you.” You follow through by checking with appropriate staff. You determine who is to inform the patient (respects the patient’s right to know).

• The doctor has ordered the patient to walk for 10 minutes out of each hour. The patient complains that it hurts and asks to not be required to walk. You respond by saying, “I know it is uncomfortable, but I will walk along beside you. We can stop briefly any time you like. I will also teach you how to do a brief relaxation technique [see Chapter 6] that you can use while you are walking.” If pain medication is available, you will also make sure that this is given before walking and in enough time for the medication to take effect (respects patient’s feelings but supports the need to carry out doctor’s orders).

• Unexpected visitors arrive when it is time for you to help the patient with personal care. You ask the patient directly if care should be done now or postponed briefly. You state the time that you will be available to assist with care (respects the patient’s right to choose, as long as it does not compromise the care).

• You have just been criticized for your work. You respond by saying, “Please clarify. I want to be sure I understand.” If the error is yours, ask for suggestions to correct it or offer alternatives of your own (separates criticism of performance from criticism of self).

• The patient asks for personal information about you (or another staff member). You respond by saying, “That information is personal, and I do not choose to discuss it” (stands up for rights without violating rights of others).

• Your patient asks you to pick up some personal items from the store. This would mean doing it on your own time, which is already very full. You respond by saying, “I will not be able to do the errand for you” (direct statement without excuses).

• The team leader has been “on your case” constantly and, you think, unfairly. You approach the team leader and say, “I would like to speak with you privately today before 3 PM. What time is convenient for you?” (direct statement of wishes).

• You are being pressed by other staff members to help with their assignments but are too busy to do so. You say, “No, I do not have the time to help today, but try me again on some other day” (direct refusal without feeling guilty; leaves the door open to help at a future date).

• Your day is overwhelming. You approach your team leader and say, “I know you would like all of this done today. There is no way I can get it all done. What are your priorities?” (direct statement of information and request for clarification).

• The doctor has criticized your work in front of the patient. You feel embarrassed and angry. You approach the doctor and ask to speak privately. Using “I-centered” statements, you begin by saying, “I feel both embarrassed and angry because you criticized me in front of the patient. Next time, ask to talk to me privately. I will listen to what you have to say” (stands up for your rights without violating the rights of others).

• You are ready to leave work, when a peer approaches you about a personal problem. You respond by saying, “I have to leave now, but I’ll be glad to listen to you during our lunch break tomorrow” (compromise).

• Another staff person moves into the cafeteria line ahead of you with a nod and a smile. You are in a hurry, too, and feel this is an imposition. You say firmly, “I do not like it when you cut in line ahead of me. Please go back to the end of the line” (stands up for your rights).

Now complete the exercise in the Try This: Identify Assertiveness box.

Try This

Identify Assertiveness

List examples of assertiveness you can identify in your own behavior or in people around you.

The following three rules are helpful overall in being assertive:

1. Own your feelings. Do not blame others for the way you feel.

2. Make your feelings known by being direct. Begin your statements with “I.”

3. Be sure that your nonverbal communication matches your verbal message.

Negative interactions: using coping mechanisms

With the availability of so many types of preparation for nurses and the lack of differentiation in roles based on preparation, nurses sometimes experience insecurity in their role and the worth of the role as they understand it. Projection is a coping mechanism during which individuals attribute their own weaknesses to others. The interaction can be characterized as “my education is better than yours” or “I’m more competent than you are” or “You’re only a practical nurse,” and so on. Unfortunately, this negative, aggressive interaction wastes energy that could be used to provide the patient with the care that is being alluded to. Nurses who are confident and assertive enhance one another’s knowledge base and legal responsibility. The patient benefits from the assertiveness.

Another negative interaction is based on a previous unresolved incident between the patient and the nurse. The nurse uses the coping or mental mechanism of rationalization, in which a logical but untrue reason is offered as an excuse for the behavior. The nurse quickly informs others that this patient is a “troublemaker” or a “manipulator” or “uncooperative.” This is a nonassertive, indirect type of behavior on the part of the nurse. Obviously, if other nurses incorporate this information into their transactions with patients, patients will never be seen as their true selves. Anything the patient does can be interpreted within the context of the label given by the nurses. A vicious circle can ensue. If the patient’s needs are not met because of this labeling, this increases his or her frustration. This in turn is a threat to self, resulting in anxiety. Depending on the patient’s personal strength at this time, the situation can lead to problem solving, the use of coping/mental mechanisms, or symptom formation (Figure 14-1).

Figure 14-1 A vicious circle showing a negative interaction from an unresolved incident between the patient and the nurse.

An honest, assertive response on the part of the original nurse involved would consist of dealing with the patient directly in regard to the previous situation. It would not involve other nurses as allies in “getting this patient.” An example of an extreme situation resulting from just such a seemingly innocent rationalization occurred at a nursing home. A young man who was paralyzed from the waist down as a result of a car accident was being transferred from one nursing home to another. A transfer form arrived before he did. The information on the form created immediate anxiety for the nurses involved before they had even met the man. The form labeled the man as “manipulative.” It stated, “He will be pleasant and polite at first, but watch out because it is a trick. When he has won you over, you will see his ‘true colors.’” The nurses discussed the prospective admission. They expressed gratitude that their colleagues in the other nursing home had warned them. After all, that is what colleagues are for. They felt, “Forewarned is forearmed.”

When the patient arrived and attempted to get acquainted, he was dealt with coldly and abruptly and made to wait. The nurses intended to show him that he could not manipulate them. As his frustration and discomfort increased, he began to demand that his treatments be done on time. He shouted angry comments at the nurses when they finally arrived to assume his care. The nurses called him “demanding” and “hostile.” The original label of “manipulative” was supported when the patient asked his roommate to put on the call light to get help to take him to the bathroom. Each day seemed worse than the day before. The showdown finally came when a longtime nurse employee left, saying that she would not come back until the patient was transferred to another facility. She would even volunteer to do the transfer note. Other nursing staff threatened to follow suit. Finally, the administrator gave in. The patient was transferred, and the nurses congratulated one another for having worked together! Complete the exercise in the Critical Thinking: Negative Interactions box.

Critical Thinking

Negative Interactions

1. What factors contributed to the patient’s behavior?

2. What factors contributed to the nurses’ response to the patient?

3. How could this situation have been handled differently?

4. Was the behavior of the nurses passive, aggressive, or assertive? Explain your answer.

Another negative transaction involves the patient’s right to know (for example, a patient being transferred from a skilled nursing home facility to an intermediate nursing home facility). This transaction can be known by many titles, depending on the issue. It can be called “I’ve got a secret”; “It is not my responsibility”; “She will be upset”; or “She is too weak to figure out what is going on.” The responsibility of informing the patient about his or her condition or transfer plans is not carried out just so the present staff does not have to deal with the full impact of the patient’s reaction to the information. The coping or mental mechanism used by the nurses is denial. The nurse refuses to recognize the existence and significance of the patient’s personal concerns. The nurse also uses denial as a way of excusing personal responsibility: “The doctor should tell him” or “It’s the team leader’s responsibility.” Although the decision may not be entirely yours, it is clearly your responsibility to check out what portion of the information is yours to give. You also have the responsibility to check out who is going to present the information and when. Complete the exercise in the Try This: Identify If Behavior Is Passive, Aggressive, or Assertive box.

Try This

Identify If Behavior Is Passive, Aggressive, or Assertive

Is the nurse’s refusal to take responsibility to seek out the information the patient needs to know a passive, aggressive, or assertive transaction? Explain your answer.

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Tags: Success in PracticalVocational Nursing From Student to Leader

Mar 1, 2017 | Posted by admin in NURSING | Comments Off

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Assertiveness: Your Responsibility

Assertiveness

Your Responsibility

Nonassertive (passive) behavior

Aggressive behavior

Assertive behavior

Negative interactions: using coping mechanisms

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Assertiveness: Your Responsibility

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Negative interactions: using coping mechanisms

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