Positive, Assertive "Pushback" For Nurses

Alabama Nurse,  Jun-Aug 2004  by Goddis, Susanne

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On one of her evening shifts, 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 from a bout of Lithium toxicity. After an i.v. was started, the patient, Miss Hawkins, developed some kidney complications, so a renal specialist was contacted. After reviewing her charts, the specialist ordered an i.v.containing dextrose.

Knowing that the dextrose could negatively affect her patient 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.

So, 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. Especially in the field of nursing, the ability to deliver an appropriately assertive response to a potentially negative and/or harmful situation is a critical -even a potentially lifesaving - skill.

And, contrary to popular belief, you can communicate your concerns without permanently damaging your professional relationship. 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. (If you want to be really assertive include the word "I," such as "I" really need for you to stop and review this now...")

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 persons 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.