Communication is an integral part of everyday life. As a nurse it is vital to be able to communicate properly and adequately. There are different types of communication, including verbal, written and oral, body language, facial expression, pictures, sign language and photographs. Communication is an exchange of information, thoughts, ideas and emotions. However the way we communicate can sometimes be misinterpreted by the recipient because we may speak aggressively when we do not intend to, or our body language may portray a different conflicting message. I have chosen assertiveness as my specific type of communication that requires developing because I struggle with assertion. This assignment intends to explore my assertiveness and how I can improve, expand and develop this method of communication. I intend to discuss what assertiveness is, what works, and what doesn’t. I will also be providing examples from areas in my personal life, my placements, and the difficulties I have encountered and how I have dealt with and tried to overcome them. In support of the above I have included a SWOT analysis and action plan which can be found in Appendices 1 & 2.
Being assertive is a way of relating to others using effective communication skills, while at the same time respecting the other person, as well as yourself to ensure that you are not being taken advantage of, Bupa 2008. Assertiveness is now being viewed as the most effective and desirable way to deal with people and is in fact a life skill. Being assertive will enable me to deal with, manage and interact with the world. This type of communication does not come naturally to me. I have been in situations where to avoid an argument I have said nothing rather than give my point of view. I need to ascertain why I find it hard to be assertive. Is this partly due to my lack of practice in this area together with the fear of provoking hostility, lack of self-esteem and feeling useless, or is it also to do with my very strict upbringing, where it was considered rude to speak out of turn or voice my own, different opinion. As a small child, it was very much a be seen but not heard scenario, this extended into late teenage years. This together with confines in previous occupations, where to speak out would be deemed as being awkward and difficult to work with has I believe restricted my ability to be assertive. I now need to learn coping mechanisms and learn to become more assertive, by being able to stand up for myself, without being stressed, and ensure that my opinions and feelings are taken into consideration. “Assertiveness involves clear calm thinking and respectful negotiation within a space where each person is entitled to their opinion”, Bupa 2008.
So how do you get your point across without shouting, raising your voice and getting
angry? How can I be assertive without being destructive and ineffective? What does being assertive really mean? The ultimate aim of assertion is for me to be myself, but it is not about me getting my own way at any cost. I am in charge of my own behaviour and it is for me to decide what I will and won’t do. I have already mentioned in my introduction the different types of communication and everyone develops their own way of using these styles. I am totally unassertive with my parents because they always make me feel a constant failure, e.g. failed marriages, single parent, shame on the family, but am able to be assertive on behalf of a patient/client/service user, because I must be a good advocate, and I feel that I am able to and can make a difference. Assertiveness will allow me to relate to others with less conflict, anxiety and resentment, Smith 2009. I need to learn that I am allowed to say no and that I don’t have to apologise for it or explain it. I need to consider my body language; I am very tall and may appear intimidating, appropriate eye contact, relaxed posture and speak clearly and evenly in an appropriate tone. My facial expression can appear very severe, which is unintentional and I need to address this. I need to be relaxed around other people and this will increase my confidence. I will be able to retain my self respect, by not walking all over others or let them walk all over me.
Being assertive is also being honest with yourself, Siviter 2005. This means knowing what I can do, knowing my limitations, letting others know what I need and how I am feeling. In my recent Nursing Home placement I unfortunately came across several situations where I felt that the service users were not receiving correct/adequate care. This situation was further exacerbated by the absence of someone with any authority to report my concerns to when my original comments were ignored. There was also a language barrier. This was because for all the staff present, English was their second language and therefore some of my concerns were lost in translation or just simply not understood. I remembered from previous lectures that if you don’t document it, it hasn’t happened. After speaking to the Registered Nurse (RN) on duty, I then documented all relevant details in the service users’ cardex. I was unable to write in the staff communication book as only trained RN’s were allowed to use this method of communication. Unfortunately, I was reprimanded by a visiting Matron from another nursing home and told that my comments were deemed inappropriate in a legal document and I was advised that I should have used the daily diary to communicate. I reflected on the feedback that I had been given, and made a conscious note to word my comments differently in future. However, although no action was taken when I communicated verbally, within 24 hours of my documentation being read, changes were made and appropriate care was given. Being assertive is also about being positive and not over reacting. Referring to the above incident, even though I was not aware of the daily diary, I remained calm, did not argue the point, did not cry, or gossip about the incident after. I did feel that the way I had been spoken to was inappropriate and unprofessional, and a staff member who was also present in the room at the time later voiced this same thought to me. However, I do feel that my ability at the time in not giving a negative reaction reflected professional assertive behaviour.
Being assertive does not mean putting your point across without regard for others by being rude, forceful or aggressive. Siviter 2005 states that being assertive is not the same as being a bully. If you feel that you are being fair and reasonable, you are within your rights to take your concerns higher. Unfortunately, I was unable to do this in my placement, I therefore adapted my assertiveness by ensuring accurate documentation which did change things and provided better care for the service user. This included correct mattresses for extensive bed sores, review of bowel medication, correct manual handling procedures, food hygiene and last offices training. I also emailed my concerns to my personal tutor and I will discuss this further at my Placement Assessment Document (PAD) meeting.
When I was hit by a service user, (Mrs A) I reported it to the RN on duty and then documented the incident. Mrs A had previously hit several other members of staff and other service users within the nursing home, but these were never officially reported. I had previously been concerned over Mrs A’s deterioration in health due to a recent fall and a few days previous to the above incident had suggested to the RN on duty that the doctor should be called due to Mrs A’s increase in aggressive and violent behaviour towards others. I had suggested this because I had experience of this type of behaviour in my previous hospital placement, and was familiar with the treatment for this type of patient. The doctor was only called after I had documented that I had been hit and the relevant medication was prescribed for Mrs A. I found this situation very difficult because I knew that Mrs A had not been receiving adequate care.
Passive aggressive behaviour is not an acceptable form of communication. Passive aggression is where due to lack of assertion you feel angry but you do not show your anger, instead you get revenge on that person by acting in a sneaky manner, e.g. gossiping, calling in sick when you are not, being routinely late for meetings, forgetting documents, doing a job so badly somebody else has to take over and do it instead. This type of assertion does not work and will reflect badly in that others begin to see you as unreliable, irresponsible, disorganised or inconsiderate, Patterson 2006. There were several instances of staff gossiping at the nursing home because staff felt overworked and put upon and due to the lack of a Matron had no one to talk to who would listen to their views and fight their corner for them.
There is also the passive style of assertion, by this I mean trying to avoid any means of possible conflict. This too will not work. Passive assertion could mean giving in to unreasonable demands from other people, not daring to say no and just going along with the crowd. You won’t offer your opinion until others have offered theirs in case yours is wrong. You would never criticise others or give negative feedback for fear of being disliked among your colleagues. You try to make yourself invisible by never saying or doing anything that might attract comments or even disapproval. Unfortunately we may then give control over to others without realising it. Body language will change to include avoiding eye contact, appearing nervous and looking down. However, the word passive is rather misleading. It does not always mean doing nothing. Often a passive person is more active than anyone else, working hard to gain approval, never saying ‘no’, always being seen to be running around, trying to solve everyone’s problems, Patterson 2006. However, long term this type of behaviour can lead to loss of self esteem. I experienced very low morale among the Nursing Home staff due to working conditions. These staff were also vulnerable because their Employer also provided their housing and therefore daring to be assertive and say ‘no’ was likely to jeopardise much more than just their job.
Aggressive assertion can be defined as the opposite of passive style assertion. This means that instead of submitting to others, we try to get others to submit to us. Aggression is almost always the result of feeling threatened and responding to this with anger. The aim of aggressive assertion is to control others through intimidation, Cloud et al 2002. Aggressive communication does not necessarily mean aggressive behaviour, but it can mean being manipulative and controlling in a more subtle manner. Personal boundaries are not respected by aggressive people and they are likely to harm others by their influence, Wikipedia 2009. I unfortunately witnessed a staff member telling Mrs A to shut up on more than one occasion and being very rude to other staff members of a different ethnicity. This person seemed to wield such power over all the other staff that her behaviour was never questioned and she was not reprimanded or disciplined. She was not afraid to say ‘no’, but unfortunately her behaviour impacted on others in not only making their behaviour even more passive, but also making them more resentful towards her.
In my Health Visitor (HV) placement I witnessed HV’s being assertive in ensuring that mothers, babies and young children were cared for correctly. Any concerns were immediately reported to the relevant person and appropriate action taken. Common Assessment Framework (CAF) meetings were held where necessary to help identify at the earliest opportunity any additional needs and to provide adequate support as soon as possible.
I also witnessed hostile, defensive parents who viewed us with suspicion. Previous experiences in child protection and deprivation enabled me to listen empathetically. Listening with empathy makes people feel understood and respected, Gouldtraining 2009. These mothers needed our help and advice, but in a manner that would not make them feel inadequate. In my PAD my mentor observed that I had good listening skills and analysis.
In conclusion, to improve my assertiveness I need to meet situations head on and not shy away from them. I must understand and act upon why I say yes when I should have said no. I need to be able to say what I mean without feeling guilty. If I have a problem I need to deal with it, e.g. speak to my mentor/personal tutor I also need to be aware of my body language. Above all, being assertive is having confidence in myself to be effective. I recognise that the above will take time and that I need to practice this form of communication wherever possible both in my personal and professional life.