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Nurse Sally Stevens, an R.N. with 17 years of
nursing experience, was caring for a new patient, a
46-year-old female diabetic, who was suffering from
tremors due to a bout of Lithium toxicity. After an
i.v. was started, the patient, Miss Hawkins, developed
some kidney complications, prompting doctors to bring
in a renal specialist. After reviewing her charts, the
specialist ordered an i.v. containing dextrose.
Knowing that the dextrose could negatively affect her
patient's diabetic condition, Nurse Sally voiced her
concerns. In a non-aggressive tone, Nurse Sally said,
"Doctor, Miss Hawkins' blood sugar was 315 at 4pm. I
noticed that you've changed her i.v. fluids to
Dextrose. Do you want to change the i.v. fluids?"
Because of Nurse Sally's ability to communicate
effectively, Miss Hawkins received the best possible
medical care.
The real moral of the fictional account of Nurse
Sally's story is that you really can get your needs
and wants met - not through aggressive, in-your-face
confrontations - but via effective, positive and
assertive communications.
A "positive pushback" is the ability to deliver an
appropriately assertive response to a potentially
negative and/or harmful situation. A positive pushback
is executed by looking someone straight in the eye,
and saying with an even, non-stressed tone what you
want or need.
Practice Makes Positive
It's critical to sound confident when you are giving a
positive pushback. A positive pushback does not leave
the other person confused or unsure about your needs,
wants, desires or message! That said, a positive
pushback is not delivered with a choppy tone of voice,
or an aggressive posture or facial expression.
Example to Lose: "I wonder if we should double check
the lab work before...?" Example to Use: "I think we
should double check the lab work before..."
Samuel Maceri, DNSc RN, and chairperson of the
commission of workplace advocacy for the Tennessee
Nurses Association offered some tips on assertive
nurse communications during potential conflict
situations: "When you call the physician at two a.m.
and you know they're tired, you can say 'I know you're
very concerned about Mrs. Johnson and I'm sure you'll
want to do something about this situation' - then
there's justification for disturbing their space and
time. It's important to first address the other
person's needs and goals."
Unfortunately, you can only conduct a positive
pushback when you have sufficient positive
psychological capital, which means that you are
equipped with enough self-esteem, self-confidence and
self-efficacy to be able to handle yourself in a
conflict situation. You must continually build this
capital up, so it will be there when/if you need it.
Positive Pushback Benefits - and Fears
One of the benefits of using a positive pushback is
that you have a good opportunity to produce the
results you want and need. Other benefits can include
an immunization against burnout (by helping you
decrease your stress level), and the building of
self-esteem and self-confidence. Also, it can help you
build positive relationships with others and empower
you become a better patient advocate.
So why don't people push back? Well, certainly fear is
a primary factor. Other factors can be prior negative
experiences (such as no one listened or listened
poorly previously), defense mechanisms (I can't be
responsible), as well as the active avoidance of a
response. Plus, some nurses are operating in a
negative organizational culture, and whatever
psychological capital they once had accumulated, may
now be depleted.
"There's a power play in any relationship," Maceri
notes," While a physician may have more experience, as
a person the physician is no more a human being than a
nurse. A nurse has the same level of human rights as
anyone. It demeans all of us when a nurse is unable to
assertively and professionally assert themselves in a
responsible and firm way."
You're Okay, I'm Not Okay: Submissive Communication
We can communicate more effectively with others when
we learn assertive, non-aggressive, communication
techniques. Perhaps the best way to understand
assertive communication, is to look at how it falls
along a continuum of three categories: 1.) submissive
(non-assertive), 2.) aggressive, and 3.) assertive
behavior.
The first category is non-assertive, or submissive,
behavior. People who typically behave submissively
demonstrate a lack of respect for their own needs and
rights. Many submissive people do not express their
honest feelings, needs, values and concerns. They
allow others to violate their space, deny their rights
and ignore their needs. Rarely do they ever state
their desires, even though it may be all that was
needed in order to have their needs met.
Some people who exhibit submissive behavior express
their needs, but do it in such an apologetic and
diffident manner that they are not taken seriously. If
you hear qualifying phrases such as: "Oh, do whatever
you want," or, "It really doesn't matter to me," or,
"I could be wrong but..." - What, in fact, you are
hearing is a form of "verbal submission." Nonverbal
submission can include a shrugging of the shoulders,
lack of eye contact, an excessively soft voice,
hesitating speech, etc.
The submissive person communicates: "I don't matter,
you can take advantage of me. My needs are
insignificant- yours are important. My feelings are
irrelevant; yours matter. My ideas are worthless; only
yours are significant. I have no rights, but of course
you do." Because the submissive person will often
quash their own needs, very often this leads to pent
up frustration and anger.
ADVANTAGES of submissive communication:
1. Submission is a way of avoiding, postponing or
hiding conflict.
2. Submissive people carry a much smaller load of
responsibility. If things go wrong, rarely is the
submissive person to blame.
DISADVANTAGE of submissive communication:
1. Pent up frustration and anger.
2. No one knows what you want, so they can't give you
what you want.
Getting What You Want at the Expense of Others:
Aggressive Behavior
On the other end of the continuum is aggressive
behavior- commonly defined as behaviors that "move
against" or "move with the intent to hurt." An
aggressive person expresses their feelings, needs and
ideas at the expense of others. They almost always win
in an argument, speak loudly and can be abusive, rude
and sarcastic. Normally, aggressive people insist on
having the final word and tend to berate, dominate and
try to overpower others. They can also be very
controlling. The aggressive person often feels that
only his or her point of view is important.
Nonverbal communication in an aggressive person can
include dominant eye contact (staring), pointing, fist
banging, a loud voice and an invasion of "personal
space". They may use terms like "always" and "never,"
as exaggerations are common. Frequently, a lot of
"you" language (such as "You never do...") is used.
ADVANTAGES of aggressive communication:
1. They are likely to secure the material needs and
objects that they desire.
2. They tend to protect themselves and their own
space.
3. They appear to retain considerable control over
their own lives and the lives of others.
DISADVANTAGES of aggressive communication:
1. Often, the aggressive person will suffer from fear.
2. The provocation of counter-aggressive behavior.
3. Loss of control, guilt and dehumanization.
I'm Okay and You're Okay Too: Assertive Communication
This method of communication allows both parties to
maintain self-respect, pursue happiness and
satisfaction of their needs, and defend their rights
and personal space - all without abusing or dominating
other people. True assertiveness is a way of
confirming your own individual worth and dignity. And
simultaneously, the assertive person confirms and
maintains the worth of others.
Assertive individuals stand up for their own rights
and expresses their personal needs, values, concerns
and ideas in direct and appropriate ways. While
meeting their own needs, assertive people do not
violate the needs of others or trespass on their
personal space. They use "I" language ("I am trying
to...") as opposed to "you" ("You can never seem
to...) language, communicate with an open stance,
maintain eye contact, and use appropriate distance,
head nods and lean forward to listen attentively to
the speaker.
ADVANTAGES of assertive communication:
1. Assertive people like themselves.
2. Assertion also fosters fulfilling relationships,
releases positive energy toward others, and greatly
reduces a person's fear and anxiety.
3. As assertion is result-oriented, your chances of
getting what you want and need are significantly
increased.
DISADVANTAGES of assertive communication:
1. Often, assertion will cause disruptions in one's
life.
In the end, the proper goal of positive pushback
training is to assist nurses in choosing communication
strategies and behaviors effectively, not to have
nurses behave assertively in every situation.
Sometimes it may be wise for you to give in to others,
and conversely, it may be necessary for you to
aggressively defend your needs and/or your patient's
rights. However, for the most part, positive pushback
can be an effective, positive and successful means of
communication for nurses working in today's healthcare
environment.
Source: Susanne Gaddis
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