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positive, assertive "Push back" for nurses

On one of her evening shifts, RN Sally Stevens, a registered nurse with 17 years of nursing experience, was caring for a new patient, a 46-year-old diabetic woman suffering from tremors due to an episode of lithium toxicity. After an IV was started, the patient, Miss Hawkins, developed some kidney complications, prompting doctors to bring in a kidney specialist. After reviewing her records, the specialist ordered an IV containing dextrose.

Knowing that dextrose could negatively affect her patient’s diabetic condition, Nurse Sally expressed her concern. In a non-aggressive tone, Nurse Sally said, “Doctor, Ms. Hawkins’s blood sugar was 315 at 4:00 p.m. I noticed she switched her IV fluids to dextrose. Do you want to switch fluids? intravenous?”

Thanks to Nurse Sally’s ability to communicate effectively, Ms. Hawkins received the best medical care possible.

Therefore, the real take-home message from the fictional account of Nurse Sally’s story is that you really can get your needs and wants met, not through aggressive, direct confrontation, but through effective, positive, and assertive communication. Especially in the field of nursing, the ability to make an appropriate assertive response to a potentially negative and/or harmful situation is a critical skill, even a potentially life-saving skill.

And contrary to popular belief, you can communicate your concerns without permanently damaging your professional relationship. A “positive rejection” is the ability to offer an appropriate assertive response to a potentially negative and/or harmful situation. A positive kickback is executed by looking someone directly in the eye and saying in an even, stress-free tone what she wants or needs. (If you want to be really assertive, include the word “I”, like “I really need you to stop and review this now…”)

practice makes positive

It is essential to sound confident when you are giving a positive response. A positive pushback doesn’t leave the other person confused or unsure about their needs, wants, or message! That being said, a positive rejection is not delivered with a breathy tone of voice or an aggressive posture or facial expression.

Example to lose: “I wonder if we should double check the lab work before…”. Usage example: “I think we should double check the lab work before…”

Samuel Maceri, DNSc RN, and chair of the Tennessee Nurses Association’s Workplace Advocacy Commission, offered some advice about assertive nurse communication during potential conflict situations: “When you call the doctor at two o’clock morning and you know you’re tired, you can say, ‘I know you’re very worried about Mrs. Johnson and I’m sure you’ll want to do something about this situation,’ then there is a justification for disturbing your space-time goals.”

Unfortunately, you can only pull back positively when you have enough positive psychological capital, which means 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, so that it is there when/if you need it.

Positive Pullback Profits and Fears

One of the benefits of using a positive retracement is that you have a good chance of producing the results you want and need. Other benefits may include an immunization against burnout (by helping you lower your stress level) and the development of self-esteem and confidence. Additionally, it can help you build positive relationships with others and empower you to become a better patient advocate.

So why don’t people back off? Well, certainly fear is a primary factor. Other factors may be previous negative experiences (such as no one heard or misheard before), defense mechanisms (I can’t be responsible), as well as active avoidance of a response. Additionally, some nurses are operating in a negative organizational culture, and whatever psychological capital they once accumulated may now be depleted.

“There is a power game in any relationship,” Maceri notes, “although a doctor may have more experience, as a person, the doctor is no more a human being than a nurse. A nurse has the same level of human rights as anyone It degrades us all when a nurse is unable to assertively and professionally assert herself in a responsible and assertive manner.”

You’re Fine, I’m Not Fine: Submissive Communication

We can communicate more effectively with others when we learn assertive and non-aggressive communication techniques. Perhaps the best way to understand assertive communication is to see how it falls on 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 tend to behave in a submissive manner show a lack of respect for their own needs and rights. Many submissive people do not honestly express their feelings, needs, values, and concerns. They allow others to violate their space, deny their rights, and ignore their needs. They rarely express their wishes, although it may be all that was needed to meet their needs.

Some people who exhibit submissive behavior do express their needs, but do so in such a timid and apologetic way that they are not taken seriously. If you hear qualifying phrases like: “Oh, do what you want” or “I really don’t care” or “I could be wrong but…” – What, in fact, are you hearing is a form of “verbal submission”. Nonverbal submission can include a shrug, lack of eye contact, an excessively soft voice, hesitancy in speech, etc.

The submissive person communicates: “It doesn’t matter, you can take advantage of

from my. My needs are insignificant, yours are important. My feelings are irrelevant; yours matters. My ideas are worthless; only yours are significant. I have not

rights, but of course I do.” Because the submissive person will often stifle 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, it’s rarely the submissive person’s fault.

3. Submissive people often seem so helpless that other people take it upon themselves to care for and protect them.

DISADVANTAGE of submissive communication:

1. Suppressed 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, 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. Typically, aggressive people insist on having the last word and tend to nag, dominate, and try to dominate others. They can also be very controlling. The aggressive person often feels that only her point of view is important.

Nonverbal communication in an aggressive person can include dominant eye contact (staring), pointing, fist bumping, loud talking, and invading “personal space.” They can use terms like “always” and “never” since exaggerations are common. Often, “you” language is used a lot (such as “You never do…”).

ADVANTAGES of aggressive communication:

1. They are likely to secure material needs and desired objects.

2. They tend to protect themselves and their own space.

3. They seem to retain considerable control over their own lives and the lives of others.

4. Often people will not approach you with their problems or raise problems with you.

DISADVANTAGES of aggressive communication:

1. Often the aggressive person will suffer from fear. Often the most

Aggressive people are the most fearful. Many people behave aggressively not because they feel strong, but because they feel weak.

2. The provocation of counter-aggressive behaviors.

3. Loss of control, guilt and dehumanization.

4. Alienation of people. Again, people will not approach you with their problems or raise issues.

5. Poor health.

I am fine and you are fine too: assertive communication

This method of communication allows both parties to maintain self-respect,

pursue happiness and the 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 value of


Assertive people defend their own rights and express their needs, values, concerns and personal ideas in a direct and appropriate way. While meeting their own needs, assertive people do not violate the needs of others or invade their personal space. Use “I” language (“I’m trying to…”) instead of “you” language (“You never seem to…”), communicate with an open posture, maintain eye contact, and use distance adequate. , nodes of the head and lean forward to listen carefully to the speaker.

ADVANTAGES of assertive communication:

1. Assertive people like themselves. Often the extent to which you affirm

you yourself determine the level of your self-esteem.

2. Assertiveness also fosters fulfilling relationships, releases positive energy towards others, and greatly reduces a person’s fear and anxiety. Also, assertive responses weaken anxiety and tension.

3. Since assertion is result-oriented, your chances of getting what you want and need are significantly increased.

DISADVANTAGES of assertive communication:

1. Often the affirmation will cause disruption in one’s life. There is also pain associated with honest and caring confrontation and often it is a personal struggle to modify your own habitual behaviors (especially for those who are changing from submissive or aggressive lifestyles).

In conclusion, it is important to note that there are times when assertive behavior is not the best option. You can convey your needs in a very positive way and still cause the other person to react in a hostile way. As in any healthy relationship, conflict is bound to arise, and being your authentic self can sometimes be a painful experience. To be assertive you have to risk dissension and make yourself a little vulnerable. However, once mastered, assertive communication will make a positive difference in your daily interactions with others.

In the end, the proper goal of positive training is to help nurses choose communication strategies and behaviors effectively, not to make nurses behave assertively in every situation. At times, it may be wise to give in to others and, conversely, it may be necessary for you to aggressively advocate for your needs and/or the rights of your patient. However, for the most part, push can be an effective, positive and successful means of communication for nurses working in today’s healthcare environment.


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