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Positive, Assertive "Pushback" For Nurses
During one evening shift, Sally Stevens, RN, a nurse with 17 years of nursing experience, was caring for a new patient, a 46-year-old diabetic woman with tremors due to lithium poisoning. After starting IVs, the patient, Miss Hawkins, developed kidney complications, prompting doctors to call in a kidney specialist. After reviewing the graphs, the specialist administered dextrose-containing iv.
Knowing that dextrose could negatively affect her patient’s diabetes, Nurse Sally expressed her concern. Nurse Sally said in a non-aggressive voice, “Doctor, Miss Hawkins’ blood sugar was 315 at 4:00 p.m. I noticed that she changed her IV fluid to dextrose. Do you want to change the IV fluid?”
Because of Nurse Sally’s effective communication skills, Miss Hawkins received the best possible medical care.
So the real moral of the fictional account of Sister Sally’s story is that you can actually get her needs and wants met—not through aggressive, confrontational communication, but through effective, positive, and assertive communication. Especially in the field of nursing, it is a critical – and even potentially life-saving – skill to respond appropriately to a potentially negative and/or harmful situation.
And contrary to popular belief, you can voice your concerns without permanently damaging your professional relationship. “Positive pushback” is the ability to respond appropriately assertively to a potentially negative and/or harmful situation. Positive feedback is done by looking someone straight in the eye and saying what you want or need in a steady, unstressed voice. (If you want to be really emphatic, put the word “I” in, like “I really need you to stop and review this right now…”)
Practice makes you positive
It is very important to appear confident when giving positive feedback. Positive pushback does not leave the other person confused or uncertain about your needs, wants, desires or message! That said, positive feedback cannot be achieved with a hoarse tone of voice, aggressive posture, or facial expression.
Example for Lose: “I wonder if we should double check the lab work before…?” Usage example: “I think you should check the lab work before…”
Samuel Maceri, DNAc RN and chairman of the Tennessee Nurses Association Workplace Advocacy Committee, offered some tips for assertive nurse communication in potential conflict situations: “If you call the doctor at two in the morning and you know he’s tired, say, ‘I know you’re worried, Mrs. . because of Johnson, and I’m sure he wants to do something about this situation’—then disrupting space and time is warranted. It’s important to address the other person’s needs first, and goals.”
Unfortunately, you can only perform positive containment if you have enough positive psychological capital, meaning you have enough self-esteem, confidence, and self-efficacy to handle yourself in a conflict situation. You need to keep building this capital so it’s there when/if you need it.
Positive Deterrence Benefits – and Fears
One of the advantages of using positive feedback is that it gives you a good chance of getting the results you want and need. Other benefits include immunizing against burnout (by reducing stress levels) and building self-esteem and confidence. It can also help you build positive relationships with others and empower you to become a better patient advocate.
So why aren’t people pushing back? Of course, fear is the primary factor. Other factors may be previous negative experiences (e.g. no one listened or listened badly before), defense mechanisms (I cannot be responsible) and active avoidance of the answer. In addition, some nurses operate in a negative organizational culture, and whatever psychological capital they have accumulated may now be depleted.
“There’s a power play in any relationship,” notes Maceri. “While a doctor may have more experience, a doctor as a person is no more human than a nurse. A nurse has the same level of human rights as anyone else. It demeans us all when a nurse can’t assert yourself confidently and professionally, responsibly and decisively.”
You’re OK, I’m Not OK: Humble Communication
We can communicate more effectively with others if we learn assertive, non-aggressive communication techniques. Perhaps the best way to understand assertive communication is to consider 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 usually behave submissively do not respect their own needs and rights. Many humble 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. They rarely express their desires, even though that may be all it takes to get their needs met.
Some show a humble demeanor, express their needs, but do so in such an apologetic and self-conscious manner that they are not taken seriously. If you hear qualifying phrases like, “Oh, do whatever you want,” or, “I don’t care,” or, “I might be wrong, but…” – What is an audition really a form of “oral submission” . Non-verbal submission can include shrugging the shoulders, not making eye contact, using an overly soft voice, hesitating to speak, etc.
The submissive person communicates, “I don’t care, you can take advantage of me
about me. My needs are unimportant – yours are important. My feelings are irrelevant; yours matters. My ideas are worthless; only yours is significant. I do not have
rights, but of course you do.” Since the submissive often eliminates his own needs, this very often leads to pent-up frustration and anger.
ADVANTAGES of humble communication:
1. Submission is a way of avoiding, postponing, or hiding conflict.
2. Obedient people have much less responsibility. When things go wrong, the obedient person is rarely to blame.
3. Submissive people often appear so helpless that others take it upon themselves to look after and protect them.
DISADVANTAGES of submissive communication:
1. Repressed frustration and anger.
2. Nobody knows what you want, so they can’t give you what you want.
Getting what you want at the expense of others: Aggressive behavior
At the other end of the continuum is aggressive behavior, usually defined as behaviors that “move against” or “move with the intent to injure.” An aggressive person expresses his feelings, needs and ideas at the expense of others. They almost always win an argument, talk loudly, and can be abusive, rude, and sarcastic. In general, aggressive people insist on having the final say and tend to scold, dominate and try to beat others. They can also be very controlling. An aggressive person often feels that only their point of view is important.
Non-verbal communication in an aggressive person can include dominant eye contact (staring), pointing, fist bumping, loud voice and invasion of “personal space”. They may use terms like “always” and “never” as exaggerations are common. They often use a lot of “you” language (such as “Never…”).
ADVANTAGES of aggressive communication:
1. Desired financial needs and objects are likely to be provided.
2. They tend to protect themselves and their own space.
3. They seem to maintain a significant degree of control over their own lives and the lives of others.
4. People often don’t come to you with their problems or ask questions.
DISADVANTAGES of aggressive communication:
1. An aggressive person often suffers from fear. Most often, most often
aggressive people are the scariest. Many people behave aggressively not because they feel strong, but because they feel weak.
2. Provoking counter-aggressive behavior.
3. Loss of control, guilt and dehumanization.
4. Alienation from people. Again, people will not come to you with their problems or ask questions.
5. Poor health.
I’m fine and you’re fine: Confident communication
This method of communication allows both parties to maintain self-respect,
to pursue happiness and satisfaction of their needs and to protect their rights and entitlements
personal space – all without abusing or dominating others. True assertiveness is a way of asserting your own individual worth and dignity. And at the same time, the assertive person affirms and maintains his value
Assertive individuals stand up for their own rights and express their personal needs, values, concerns, and ideas in a direct and appropriate manner. While satisfying their own needs, assertive people do not violate the needs of others or invade their personal space. They use “I” language (“I’m trying…”) versus “you” language (“You can never seem…”), communicate with an open stance, maintain eye contact and use appropriate distance, nod and lean forward , to listen carefully to the speaker.
ADVANTAGES of assertive communication:
1. Assertive people like themselves. It’s often the degree to which you state it
You determine your level of self-esteem.
2. Assertion promotes fulfilling relationships, releases positive energy toward others, and greatly reduces an individual’s fear and anxiety. In addition, assertive responses reduce anxiety and tension.
3. Because assertiveness is results-oriented, the chances of getting what you want and need increase significantly.
DISADVANTAGES of assertive communication:
1. The statement often causes confusion in one’s life. There are pains associated with honest and caring confrontation, and it is often a personal struggle to change one’s own habitual behavior (especially for those transitioning from submissive or aggressive lifestyles).
In conclusion, it is important to note that there are times when assertive behavior is not the best choice. You may convey your needs in a very positive manner and yet the other person reacts unfriendly. As in any healthy relationship, conflicts can occur, and being yourself can sometimes be a painful experience. To be assertive, you have to risk disagreements and make yourself a little vulnerable. However, once mastered, assertive communication will make a positive difference in your daily interactions with others.
The ultimate goal of positive pushback training is to help nurses choose effective communication strategies and behaviors, not to force nurses to behave assertively in all situations. Sometimes it may be wise to yield to others and, conversely, it may be necessary to aggressively defend your needs and/or your patient’s rights. However, positive pushback can mostly be an effective, positive and successful communication tool for nurses working in today’s healthcare environment.
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