Communicating assertively and responsibly with aggressive clients and colleagues

1. Describe the problems presented by aggressive behavior

2. Identify strategies to communicate effectively with aggressive clients and colleagues

3. Formulate an assessment and intervention for given situations involving aggressive behavior

4. Participate in exercises to build skills to communicate with aggressive clients and colleagues

Courage is fire, and bullying is smoke.

Why aggressive behavior is problematic for nurses

Aggressiveness refers to rejecting, hostile, abusive, bullying, and manipulative behaviors. Patient safety is compromised by intimidating communication. In 2008 The Joint Commission introduced new standards, which took effect in January 2009, requiring more than 15,000 accredited healthcare organizations to establish a code of conduct to define acceptable and unacceptable behaviors among healthcare professionals with a formal process to manage unacceptable behavior (Joint Commission, 2008). “The presence of intimidation in the workplace, whether directly experienced or simply witnessed, has an adverse effect on healthcare providers, patients, and their families” (Lamontagne, 2010, p. 63). Verbal abuse is “communication via behavior, tone or words that patronize, demean, isolate, disparage, threaten or accuse, or intend that the individual feel attacked or humiliated” (Christman, 2007, p. 365). Workplace bullying occurs when “the victim is subjected to a series of systematic stigmatizing attacks from a fellow worker or workers which encroach on his or her civil rights” (Quine, 2001, p. 74). Lewis (2006) contends that bullying is a learned behavior in the workplace rather than an individual personality deficit. New employees may be tested, hazed, as a part of the culture, and accepted as “just the way things are” (Lamontagne, 2010). Student nurses and new graduates are often the most vulnerable. It is imperative that nurses learn to deal with aggressive behavior. Aggressive behavior may be a result of anger, an emotion that arises in response to feeling powerless or out of control. The frenzied pace of living, shift work, long hours, perceived harassment from management to “do more with less,” increased technology, and “technological stress” set the stage for workplace anxiety and anger. People become irritable and angry, which can lead to a breakdown in communication and aggression (Helge, 2001c; Hollinsworth et al, 2005). Aggressiveness may also indicate another person’s lack of respect for our feelings or a violation of our right to be treated with courtesy and consideration. In any case, aggressiveness is unpleasant.

Most of us would like to stand up for our right to be treated with respect in a way that is firm and effective (puts a stop to the aggressive behavior) and embarrasses neither us nor the other person; in other words, we want to handle the aggression assertively and at the same time consider the other person’s point of view. Our fears are that we will become enraged and lash out at the other person, fueling the fires of escalating aggression, or that we will remain tight-lipped and slink away, carrying around the smoldering wish that we could more effectively deal with an attacker. “Anger is the most misunderstood emotion in the workplace” (Helge, 2001a). If we understand that anger is based on a sense of powerlessness, frustration, and fear of loss of control, we can understand our own discomfort and the discomfort of others with its expression. Our fears of losing control or embarrassing ourselves, or our insecurity in our ability to communicate assertively and deal with the oppression, keep us from acting effectively.

When we encounter aggressive behavior, our self-esteem and physical safety are threatened. This chapter helps you deal with aggression so that you feel confident and comfortable.

How to communicate effectively with aggressive clients and colleagues

Before you deal with aggression or anger remember to breathe deeply and remain calm. Try to separate the problem from the person and avoid taking the behavior personally. Pay attention to people’s personal space, do not move in too close, and choose your words carefully to demonstrate respect for the other person (Helge, 2001b). Remember that assertive communication is crucial to dealing effectively with conflict (Antai-Otong, 2001).

Jakubowski and Lange (1978) outline the following ways of dealing with aggression from others.

Get to the source of the problem

Asking for more information—so that you are clear about the reason for your aggressor’s discontent—demonstrates your interest and opens up a dialogue that can lead to resolution of the problem. Finding out what is causing the aggressor to attack you is a logical place to begin.

For example, you might ask your supervisor, who has just reprimanded you for telephoning the intern on call about one of your seriously ill clients, this question:

Assertive response: “I see that you are angry that I phoned Dr. Jones about our client’s unstable vital signs. Could you tell me what upsets you about my calling her?”

This respectful acknowledgment of your aggressor’s message allows him or her to clarify the problem. Using an empathic response demonstrates your understanding of the other’s feelings and can disarm the aggressor enough to minimize the aggression. The open-ended phrasing of your questions is less threatening than an aggressive approach such as asking “Why are you trying to stop me?”

Increase your aggressor’s awareness of abusive behavior and its negative effects

Asking questions to determine whether your aggressor is aware of the insulting impact that aggression can have and pointing out the effect of the behavior is a technique to heighten the awareness of an aggressor. Be aware that some people are beyond caring about the effects of their behavior when they are losing control; therefore, when to use this strategy is a judgment call.

For example, after repeated abuse and criticism from the resident on call, you tell him the following:

Assertive response: “Dr. Smith, you may not realize that you are raising your voice and swearing at me. This approach makes working with you unpleasant. I would be glad to talk with you when you can lower your voice and not swear at me.” (When someone is repeatedly aggressive, using the “I feel . . . ” portion of the assertive statement may give the person more ammunition. Comment, instead, on the results of the behavior and then make your request for a behavior change.)

Remaining calm and controlled in the face of an aggressor provides a contrast that may help that person realize that aggressive behavior is out of line.

Limit the aggressive behavior

Using a CARE (Clarify, Articulate, Request, Encourage) confrontation (see Chapter 23) lets your aggressor know, in no uncertain terms, what bothers you about his or her behavior and what changes you would like to see. Sometimes, ignoring or dismissing the aggression and continuing with your own agenda takes the wind out of an aggressor’s sails and puts the emphasis on more pressing items.

For example, you are giving the end-of-shift report to the evening staff, and one evening nurse repeatedly interrupts, quizzing you on an irrelevant matter. You curtail her aggression with the following response:

Assertive response: “Sharon, I’d like to finish the report, so please hold your questions and talk to me about it later.”

For each aggressor and situation you will have different expected outcomes and will want to use different assertive strategies. What is important is that you develop skills for dealing assertively with aggression so that you can maintain your self-respect while being courteous, and that you have “a constructive impact on the other person” (Jakubowski and Lange, 1978). As a nurse, you must not tolerate continued aggression against yourself if you intend to preserve your self-esteem and credibility with clients and colleagues.