AORN JOURNAL APRIL 1993. VOL 57, NO 4

Assert Yourself EFFECTIVE COMMUNICATION FOR NURSES

Robert Goodall

e all have been faced with circum- stances that challenge our communi- W cation skills. How would you

respond to the following situations? You are the only nurse and only female member of a committee. All the other members are male physicians. The chair- man asks you to take minutes. You are at a staff meeting, and a col- league interrupts you for the third time in 10 minutes. You notice that a fellow staff nurse has just made his third minor error in as many hours. A staff nurse arrives late again, for the fourth time this month. As head nurse, you know you must say something to her.

It is your daughter’s birthday. You have spent the last 10 days planning a party for her after work. Five minutes before you had planned to leave, an employee whom you supervise asks you about a problem.

Faced with an uncomfortable communica- tion situation, we tend to respond with fear or anger. Such situations trigger the “flight or fight” response: we tense up, rational thought gives way to emotion, and we prepare for the worst. Unfortunately, if we act on our instincts, we often make the situation worse. It is impor- tant to discover and practice a more rational response to difficult situations. That response is assertion.

Communication Responses

Robert Goodall, M A , is the manager of educa- tion services at the British Columbia Health Association, Vancouver. He earned his bache- lor and master of arts degrees at the University of British Columbia, Vancouver.

A ssertion experts categorize responses to situations as unassertive, aggressive, .or assertive.

Unassertive. Unassertive behavior means giving in quickly to another’s needs o r demands, denial of one’s own needs or rights, difficulty saying “no,” and excessive nervous- ness or anxiety in conflict si tuations. In responding to the minute-taking situation, an unassertive nurse would meekly accept the role assigned by the chairman, even if she felt it was unfair or discriminatory. Another aspect of unassertive behavior is that the nurse may take out her aggression on others in a covert man- ner. For example, she may become the source of a negative rumor about the physicians on the committee. The unassertive nurse also may

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Assertive communication takes the rights and feelings of others

into account.

become the aggressor in another situation, pun- ishing a weaker colleague for the actions of the physicians.

Many of us were taught that it is “nice” to be considerate of others and to limit our own needs in favor of theirs. Unfortunately, we have come to equate open expression of our own needs with selfishness or rudeness, and we sti- fle ourselves even when it would be better to speak up.

Aggressive. Insensitivity to the needs and communications of others, attempts to domi- nate or exert power over others, and strong emotions characterize aggressive behavior. Aggressive people focus entirely on winning- every conflict is a battle. While aggressive peo- ple have no trouble expressing their own views and needs, they pay little attention to the needs of others. They tend to assume that other peo- ple are out to get them, whether it is true or not. In the minute-taking example, an aggressive response would be something like, “Absolutely not-I will not put up with this sexist discrimi- nation.”

Assertive. The direct, honest, appropriate expression of one’s thoughts, needs, or rights without undue anxiety is assertive behavior.’ The message is clear and is not manipulative. An assertive person comes straight to the point and says what is meant and felt. The actions and tone of voice match the words. Assertive communication also takes the rights and feel- ings of others into account. Two-way commu- nication is encouraged.

A simple assertive response to the minute- taking situation might be, “No, I would rather not take minutes this time.” If the nurse wanted to be somewhat more conciliatory and con- structive, an alternative could be, “Yes, I will take minutes today if we can agree to rotate this responsibility at subsequent meetings.” An assertive response is distinguished from an

aggressive response because it is more open, polite, and calm while remaining direct and straightforward. Assertive responses do not blame or deliberately intimidate. They are intended to clarify and resolve problems.

Important Considerations

ssertion depends on what is said and how it is said. Body language and tone A of voice often communicate more than

the actual words. Faced with a discrepancy between words and actions, people invariably believe the actions. To be effective, assertion cannot be simply a “technique” superficially grafted onto one’s personality. It must be based on a clear understanding and acceptance of one’s rights and the rights of others, self-confi- dence, and emotional stability.

The situation’s time and place also is a con- sideration. Delivering a reprimand in front of the recipient’s colleagues or friends usually is not considered assertive, no matter how openly or calmly it is delivered. When discussing sen- sitive matters, a private setting and a time when the other party will feel comfortable and confi- dent are appropriate considerations.

Assertion is a choice. In the film Responsible Assertion, the instructor uses the analogy of karate.? Just because a person knows karate, it does not mean he or she will choose to use it in every difficult situation. Sometimes, it may be more appropriate to back down and retreat. The same is true of assertion. There are some situa- tions when assertive behavior may not be worthwhile or assertion may be insufficient and a more aggressive approach is necessary.

The nurse in the minute-taking example may believe that taking minutes is no burden and that to refuse would create ongoing friction with the physicians. In other extreme circum- stances, the nurse may feel that the only way to

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be heard and respected would be to respond very strongly. That is the nurse’s choice.

Whichever choice is made, the nurse must be prepared to take responsibility for it and deal constructively with the consequences. If the nurse chooses to respond unassertively, he or she must recognize that the choice is made and take measures to counteract the potential nega- tive side effects. For example, instead of going home and taking out frustrations on family members, the nurse could take some time out for physical exercise that may help dissipate some of the anger created by the situation. Sometimes just knowing consciously that he or she made a choice can free a person from guilt or anger.

Assertion does not guarantee success. While it is more likely to result in beneficial conse- quences, there are certain situations in which people will prove intractable. If assertion does not work, even after several attempts, another tactic may be necessary. For instance, the nurse on the committee may decide to talk to the chairman privately, refer the matter to her supervisor, or even resign from the committee. It is important to keep reasonable expectations for assertion-it does not cure all ills.

Personal, Role Rights

ne important foundation of assertion is a clear understanding of rights. Rights 0 can be divided into personal rights and

role rights. Personal rights. “Anything you consider all

people are entitled to be, have, or do by virtue of their existence as human beings” are person- al rights.3 If a person would grant a right to oth- ers in similar circumstances, he or she can safe- ly claim it for his or her own. Personal rights typically include such things as the right to express oneself, to ask for what one wants (but not necessarily to get it), and to expect respect- ful treatment. Following are some examples of personal rights.

I have the right to express myself provided I do not set out to hurt or put others down in the process (so does everyone else).

I have the right to deal with people with- out needing their approval (so does everyone else).

0 I have the right to ask for what I want (so does everyone else).

0 I have the right to change my mind (so does everyone else).4

Role rights. Anything that other people are entitled to be, have, or do by virtue of their official role or function are role rights. For example, a head nurse may have certain role rights (eg, the right to make final decisions about staff scheduling) that are not available to staff nurses.

On the surface, the question of rights seems simple. It is important, however, to remember that rights vary among cultures. We may take for granted the right to free expression of thoughts and opinions, but not all societies accept this right. For example, what seems to be rude, abrupt, or disrespectful behavior in North America may be perfectly acceptable in New Zealand or Australia. Disagreements about rights usually are disagreements about values.

Uncertainty about rights can impede assertive communication. In everyday situa- tions, a person should carefully consider his or her own thoughts and beliefs, pay attention to the thoughts and beliefs of others, and be pre- pared to negotiate differences of opinion. An assertive person bases communication on what he or she believes are his or her rights after careful consideration. The person is prepared, however, to make adjustments in the face of convincing contrary arguments.

Self-control

nother important basis for assertion is self-control. When faced with a diffi- A cult situation, people often leap to the

worst possible conclusions. What might that nurse on the committee be thinking? She may be thinking, “If I refuse to take the minutes, these guys are going to hate me, the chairman will get angry, and there will be a terrible scene.”

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When people are fearful, it is common to overemphasize the catastrophic. It is important to regain control over fears before responding to a situation; this process may take only a few seconds. A procedure called cognitive restruc- turing can help set the stage for an assertive response. This procedure follows.

0 Identify what you are instinctively saying to yourself (ie, “self-talk”).

0 Separate what is reasonable and rational about your self-talk from what is exagger- ated, unlikely, and overly emotional.

0 Consider whether your self-talk is related to unrealistic expectations you have about your own or others’ performance.

0 Consider whether your self-talk is likely to be helpful and whether it will reduce or increase the emotional conflict?

Taking a deep breath and mentally “checking off” the items on this list can help a person respond more calmly and rationally while still ensuring that he or she asserts an opinion.

Key Behaviors

fter the foundation for an assertive response is established, people should A practice some important key behaviors.

Those behaviors can be divided into two cate- gories: talking and listening.

Talking. Key behaviors related to talking follow.

1. Pause before responding. Take a deep breath, identify your personal and role rights, and control your self-talk. You can even say, “I need a minute to think about that.”

2. Use short sentences. When nervous, many people talk to excess. Without seeming abrupt, limit the length of your response, keep your message clear and direct, and do not confuse the other party by saying too much at once.

3. State what you want or how you feel and then wait for a response. Continuing to talk is a defense mechanism. Give the other party a chance to respond to your first thought before continuing. He or she

may even agree with you. 4. Control your body language. Try to main-

tain normal eye contact-not staring, but not avoiding the other’s eyes either. Keep your hands away from your face and maintain an “open” posture. Speak in a calm, firm voice. Avoid ending sentences with “okay?” (which implicitly asks for the other party’s permission).

5 . Suggest alternatives. During the course of the conversation, make use of the first opportunity that presents itself to move toward thinking of constructive solutions. Draw people away from acrimonious debates about past behavior. Focus on the future.

Listening. Key listening behaviors follow. 1. Show the other party that you want to lis-

ten. Use encouraging words (eg, “yes,” “uh huh,” “go on”) and look attentive.

2. Clarify the meaning and feeling of the other party’s messages (eg, “Do you mean that?’ “It sounds like this really is impor-

3. Express empathy. Let the other party know you have heard and understood his or her concerns, even though you may disagree. Show him or her that you can see the situation from his or her point of view.

4. Provide a genuine personal response. Speak from the heart, not a text. Try to incorporate the principles of assertion into your natural style. Using superficial tech- niques will seem manipulative and will discourage open communication.

Assertion takes time and constant practice to master. People should start using it in relatively simple situations before tackling major con- flicts. When a person becomes proficient, he or she can start reaping the rewards of assertion:

tant to you.”).

0 a reduction of stress and tension, the prevention of “blow ups,”

0 less manipulative behavior, 8 more honest and satisfying relationships, 0 improved self-confidence, and 0 clearer, more accurate communication. Assertion is not magic, but in combination

APRIL 1993, VOL 57, NO 4 AORN JOURNAL

with other measures, it can make life more pleasant and productive at work and at home. 0

Notes 1 . D Cawood, Assertiveness f o r Managers:

Learning Effective Skills for Managing People, third ed (Vancouver, British Columbia: International Self- Counsel Press, 1992) 8.

2. A Lange, P Jakubowski, Responsible Assertion (Champaign, Ill: Research Press, 1978) motion pic- ture.

3. C Kelley, Assertion Training: A Facilitator’s Guide (La Jolla, Calif University Associates, 1979) 57.

4. M Bond, “Assertive rights and body language,” Nursing Times 84 (March 16-22, 1988) 67.

5. J Steinmetz et al, Managing Stress Before It Manages You (Palo Alto, Calif: Bull Publishing Co, 1980) 39-55.

Suggested reading Bara, M; Rugg, M. “ ‘I’ assertive communication for

effective leadership.” The Canadian Nurse 85 (October 1989) 19-20.

Bond, M. “Asser t ive discussion: Making your point.” Nursing Times 84 (March 23-29, 1988)

Bond, M. “Giving compliments and criticism.” Nursing Times 84 (April 13-19, 1988) 75-78.

Bond, M. “Making requests assertively.” Nursing Times 84 (March 30-April 5 , 1988) 77-80.

Bond, M. “Responding to feedback.” Nursing Times 84 (April 20-26, 1988) 75-78.

Bond, M. “Saying no assertively.” Nursing Times 84 (April 6-12, 1988) 63-66.

Bond, M. “Understanding assertiveness.” Nursing Times 84 (March 2-8, 1988) 61-64.

Bond, M. “When and why non-assertive?” Nursing Times 84 (March 9-15, 1988) 69-72.

Eilers, M K. “How assertive are you?” Nursing90 20 (January 1990) 124- 125.

Gassert, C A . “Are you an assertive person?” Nursing90 20 (May 1990) 163.

Gerry, E M. “An investigation into the assertive behaviour of trained nurses in general hospital settings.” Journal of Advanced Nursing 14 (December 1989) 1002-1008.

Slater, J. “Effecting personal effectiveness: Assertiveness training for nurses.” Journal of Advanced Nursing 15 (March 1990) 337-356.

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Competency of New Nurses Lacking According to a survey of 80 hospital nursing executives and 22 nursing school administra- tors in Virginia, registered nurses just out of nursing school cannot always perform the work expected of them.

are stressed in RN degree programs. While schools focus on nursing tasks, hospitals increasingly expect RNs to think critically, work in interdisciplinary teams, resolve con- flicts, and communicate, according to an article in the Dec 5, 1992, issue of Hospitals. Additionally, hospital executives cite direct patient care as comprising only 60% of nursing duties. Nursing school administrators cite direct patient care as comprising 90% of nurs- ing duties.

Nursing executives believe nurses lack com- petency in IV therapy, caring for heavily acute patient loads, caring for more than two patients, working within new patient care prac- tice models, case management, leadership and collaboration, awareness of total quality man- agement, and awareness of the health care leg- islative and financial environments.

Suggestions for increasing nurses’ compe- tency levels in these areas include creating paid internships to allow new nurses to acquire skills at a lower cost to the employer, establishing hospital-based support groups to ease culture shock, changing nursing schools’ curricula to enfold hospitals’ expectations of nurses, and organizing communication between hospitals and schools to foster better planning.

Hospitals now emphasize skills that rarely

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