Responsible, assertive, caring communication in nursing

Objectives

1. Identify the functions of interpersonal communication in nursing

2. Distinguish between assertive, nonassertive, and aggressive communication

3. Identify a three-step process to build assertiveness skills

4. Identify assertive rights

5. Identify irrational beliefs that impede assertive communication

6. Explain the DESC (describe, express, specify, consequences) script for developing an assertive response

7. Identify three types of assertions

8. Identify three essential criteria for presenting an assertive response

9. Describe the behavior of an assertive nurse

10. List the advantages of assertive communication

11. Describe responsible communication in nursing

12. Discuss the role of caring in nursing

13. Participate in exercises to build skills in responsible, assertive, caring communication

Caring is the essence of nursing.

Jean Watson

This book is designed to help you improve your ability to communicate assertively and responsibly with your clients and colleagues and to demonstrate caring, what Kleen (2004) calls a professional core belief, as you explore and respond to the uniqueness of each individual (Wilson, 2008). Nursing students can make use of this book as they begin their professional journey. Practicing nurses will also find this work useful as they come to understand that clear communication is an essential ingredient for success in a rapidly changing healthcare climate. Communication with clients, colleagues, administrative officials, and staff members of other community agencies is essential as nurses’ roles change and more nurses move into the community to practice. If you have not read this book’s introduction, do so now, and remember this as an important practice when reading a text, to be able to read actively, seeking to explore the intention of the book, posing questions to yourself as you read to help you fit what you read into your own experience, to retain content, and to be an adult learner, growing your own skills for health caring.

Next, you need to understand the meaning of four important concepts introduced in the opening sentence: communication, assertiveness, responsibility, and caring. These concepts are significant because they form the framework of this textbook.

WIT&Wisdom

Communication is the heart of nursing . . . your ability to use your growing knowledge and yourself as an instrument of care and caring and compassion

JoEllen Goertz Koerner, 2010

The meaning of interpersonal communication

Communication involves the reciprocal process in which messages are sent and received between two or more people. This book focuses on the communication exchange among you, the nurse, and your clients and colleagues. Communication can either facilitate the development of a therapeutic relationship or create barriers (Stuart, 2009).

In general, there are two parts of face-to-face communication: the verbal expression of the sender’s thoughts and feelings and the nonverbal expression. Verbally, cognitive and affective messages are sent through words, voice inflection, and rate of speech; nonverbally, messages are conveyed by eye movements, facial expressions, and body language. Communication by telephone or other electronic media loses the impact of gestures and other nonverbal communication. Powerful nonverbal messages can stand alone: a suspicious glance, for example, or a warm smile or eyes widened with fear.

Senders determine what message they want to transmit to the receiver and encode their thoughts and feelings into words and gestures. Senders’ messages are transmitted to the receiver through sound, sight, touch, and, occasionally, smell and taste.

Receivers of the messages have to decode the verbal and nonverbal transmission to make sense of the thoughts and feelings communicated by senders. After decoding the senders’ words, speech patterns, and facial and body movements, the receivers encode return messages, either verbally through words or nonverbally through gestures.

In an interaction between two people (e.g., a nurse and a client), each person is both a sender and a receiver and alternates between these two roles. When senders are speaking, they are also receiving messages from the person who is listening. Listeners not only are receiving speakers’ messages but also are simultaneously sending messages. Figure 1-1 illustrates this reciprocal nature of the communication process.

FIGURE 1-1 Reciprocal nature of interpersonal communication.

At any point in an interpersonal communication, verbal and nonverbal messages about thoughts and feelings are sent and received. With little prompting you know that the complex process of interpersonal communication is influenced by many variables that affect how messages are sent and received. Take a few minutes to think of the variety of factors that can affect the exchange of messages between people. Add your own ideas to those in the following list:

• Environmental factors: formality, warmth, privacy, familiarity, freedom or constraint, physical distance between people, climate, mood, architecture, arrangement of furniture

• Territory and personal space: crowding, seating arrangements, roles, status, position, physical characteristics (size, height)

• Physical appearance and dress: body shape, race, body smell, hair, gender, body movements, body adornments, posture, age

• Nonverbal cues: facial expressions, eye movements, vocal cues

• Intrapersonal factors: developmental stage, language mastery, differences in perception, differences in decision-making processes, differences in values, self-concept

• The use of “I” messages to own one’s responses, such as, “I don’t agree with you,” instead of “you” messages, which sound blaming, such as, “You are wrong”

Note that any of the preceding factors has the potential to facilitate communication or to act as a barrier to effective communication, depending on the situation. When these factors are considered, the interpersonal communication process looks something like the diagram shown in Figure 1-2.

FIGURE 1-2 Factors influencing interpersonal communication.

An important function of communication is to transmit messages from one person to another. The real purpose of communication is to create meaning. Senders of messages wish to convey meaning to receivers, and vice versa. With this intent, senders choose certain words and gestures in a manner that they believe is congruent with their intended messages. The sender’s objective is to transmit a message to receivers that is clear and understandable.

The purpose of communication does not stop there, however. The real purpose of creating understanding in another person is to influence the other person to effect some change. The sender attempts to persuade the receiver to respond to the sender’s requests. Requests from clients and colleagues may be for the following:

Requests may be stated in obvious or indirect ways. The following examples illustrate both direct and indirect requests.

A client has postoperative pain. His physiological need is for pain relief. He asks you, “When was the last time I had my painkiller?” (He winces and holds his wrist.) His direct request is for information about the time of his last analgesic. His indirect request is for information about when he can have more. He is anticipating action (you giving him the medication) so that he will be comforted.

A nursing assistant says at the beginning of the shift: “I have a terrible headache. I was up for 3 hours last night with my sick daughter. Do you have an aspirin?” Her physiological need is for rest and pain relief. Her obvious requests are for understanding (for you to empathize with her pain) and action (for you to give her an aspirin). She is possibly hoping that you will comfort her by making allowances for the fact that she is not at her best.

A nurse, newly hired to a unit, needs to feel that he belongs to and fits in with the group. When he asks you to show him around the unit, he is indirectly asking you to understand that he feels alone and unsure. He is directly asking you to take action to orient him and provide him with information about procedures and policy. He is likely hoping that you will make him feel welcome (comforted).

In your interpersonal relationships as a nurse, you will act as both sender and receiver. The purpose of this book is to help you develop your clarity as a sender and your comprehension as a receiver of messages. You will learn how to deliver assertive and responsible messages and to accurately decode messages from your clients and colleagues. You will be able to confidently interpret both direct and indirect requests and make responsible decisions about how to respond assertively (Box 1-1).

Box 1-1 Important Functions of Interpersonal Communication in Nursing

• Communication is the vehicle for establishing a therapeutic relationship.

• Communication is the means by which people influence the behavior of others, and thus it is critical to the successful outcome of nursing intervention.

• Communication is the relationship itself, because without it, a therapeutic nurse–client relationship is impossible.

From Stuart GW: Principles and practice of psychiatric nursing, ed 9, St. Louis, 2009, Mosby.

The meaning of assertive communication

Moments of Connection…

A Student Nurse Reflects

The woman was lying in her hospital bed. She had remained distant in conversation. She had no family members visiting her and no one could get to know her. It wasn’t until I suggested a bath that she began to warm up. She began to talk and her stories flowed one to another. At the end of her morning washing-up, she said thank you. It was as if she was a different person. As I turned to leave, she grabbed my hand, looked into my eyes, and said, “You made me feel human again.” I smiled and said it was my pleasure. I never realized the impact of what to me seemed a small part of my day. This was my second semester in nursing school . . . I felt a real connection.

Assertiveness is the key to successful relationships for the client, the family, the nurse, and other colleagues. It is the ability to express your thoughts, your ideas, and your feelings without undue anxiety without any expense to others. Assertiveness means being clear about what you need and respectful in your language and behavior.

The assertive nurse appears confident and comfortable. Assertive behavior, an active behavior, is contrasted with nonassertive or passive behavior, in which individuals disregard their own needs and rights, and aggressive behavior, in which individuals disregard the needs and rights of others. The assertive nurse is positive, caring, nonjudgmental, clear, and direct without threatening or attacking (Table 1-1).

Table 1-1

Assertive and Nonassertive Styles of Communication

CHARACTERISTIC	ASSERTIVE	NONASSERTIVE	AGGRESSIVE
Attitude toward self and others	I’m OK You’re OK	I’m OK You’re not OK	I’m OKYou’re not OK
Decision-making	Makes his or her own decisions	Lets others choose for him or her	Chooses for others
Behavior in problem situations	Engages in direct, fair confrontation	Flees, gives in	Is outright assaultive
Verbal behaviors	Clear, direct statement of wants; objective words; honest statement of feelings	Apologetic words; hedging, rambling; failure to say what is meant	Loaded words; accusations; superior haughty words; labeling of other person
Nonverbal behaviors	Confident, congruent messages	Actions instead of words (not saying is what is felt); incongruence between words and behaviors	Air of superiority; flippant, sarcastic style
Voice	Firm, warm, confident	Weak, distant, soft, wavering	Tense, shrill, loud, cold, demanding, authoritarian, coldly silent
Eyes	Warm, in contact, frank	Averted, downcast, teary, pleading	Expressionless, cold, narrowed, staring
Stance	Relaxed	Stooped; excessive leaning for support	Hands on hips; feet apart
Hands	Gestures at appropriate times	Fidgety, clammy	Fists pounding or clenched
Pattern of relating	Puts himself or herself up without putting others down	Puts himself or herself down	Puts himself or herself up by putting others down
Response of others	Mutual respect	Disrespect, guilt, anger, frustration	Hurt, defensiveness, humiliation
Consequences of style	I win, you win; strives for “win-win” or “no-lose” solutions	I lose, you lose; succeeds only by luck or charity of others	I win, you lose; beats out others at any cost

Modified from Piaget G: Characterological lifechart of three fellows we all know. In Phelps S, Austin N: The assertive woman, San Luis Obispo, Calif, 1975, Impact Publishers; and Gerrard B, Boniface W, Love B: Interpersonal skills for health professionals, Reston, Va, 1980, Reston Publishing.

Assertive communication is a lifelong learning skill that requires time and practice. Be willing to accept the fact that you will make mistakes. Be patient. When a person accustomed to behaving passively tries on this new behavior, the results may seem abrupt and abrasive, or shy and tenuous. The goal is not to be continually confrontational. When learning this new skill, you must be assertive all the time or you will be seen as nonassertive. When you practice techniques to learn to become more assertive, it is helpful to begin in a supportive environment with people who are accepting of you. Consider sharing your reading material on assertiveness with a roommate, spouse, or friend with whom you can begin practicing your assertive behavior. Start with small issues such as returning a damaged product to a store or offering a compliment.

Assertiveness is a matter of choice. It is important to feel confident that you can speak up for yourself, yet it is not necessary or even wise to speak your mind in every situation. With each person you encounter in any situation, you have the choice of communicating in an assertive or nonassertive style. The words you choose and the way you express them can be assertive, nonassertive, or aggressive. Realistically, you may not always have the energy or desire to assert your rights or express yourself fully. There are times when people cannot respond rationally, such as when they are experiencing high levels of anxiety or panic. A person might fear retaliation from a manager or fear the loss of a job. You must choose the issues for which your assertive behavior is appropriate as well as when, where, and with whom to express your assertiveness. The goal in this text is to help you develop the skills that will enable you to choose to act in the best interests of yourself and your clients. Remember, assertiveness helps you give or receive immediate feedback about a behavior that might have serious consequences if ignored (Grover, 2005). This “positive pushback” might be live saving (Gaddis, 2008).