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Positive, Assertive "Pushback" For Nurses

By Susanne Gaddis

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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.

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