Nurse-Patient Relationship Assertive Communication in Nursing

BSN509 Therapeutic Communication Nurse-Patient Relationship Assertive Communication in Nursing Semester 1 , 2023-2024 Week 5 Reviewed by: Dr Maeve Anne O Connell RM RGN RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 1  Learning Outcomes By the e...

BSN509 Therapeutic Communication Nurse-Patient Relationship Assertive Communication in Nursing Semester 1 , 2023-2024 Week 5 Reviewed by: Dr Maeve Anne O Connell RM RGN RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 1  Learning Outcomes By the end of the session, the student will be able to: Identify nurse-patient relationship and discuss the phases of nurse-patient relationship. Identify assertiveness and assertive communication. Recognize the different types of assertiveness. Discuss the advantages of assertive behavior. Identify how can we learn assertiveness and be therapeutically assertive. Discuss the characteristics of assertive nurse. Distinguish between assertive, passive , and aggressive communication and discuss the consequences of aggressive behavior. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 2 Nurse-Patient Relationship Nurse- Patient relationship: Is a professional relationship that is establishes to help the patient achieve and maintain optimal health. Phases of the Nurse-Patient Relationship ₋ Pre-interaction phase. ₋ Introductory / orientation phase. ₋ Working phase. ₋ Termination phase. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 3  1.Pre-Interaction Phase The pre-interaction phase begins before the nurses first contact with the patient. ‫التحضير للقاء األول مع العميل‬. This involves preparation for first encounter with the client. Task of Pre-Interaction Phase: ₋ Obtaining available information about the patient. From this information the initial assessment is begun. ₋ Examining one's feelings, fears and anxieties about working with a particular patient. ₋ Set objective for the interaction phase. ₋ Take help of the clinical supervisor or co-workers to overcome fears. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 4  2. Initiation/ Introductory/ Orientation Phase Begins when the nurse goes to the patient, introduces herself and gets introduction about him. This phase ends when the nurse and the patient begin accept to each other as a unique human being. Tasks of Introductory Phase ₋ Establishment of Contact (build trust, establish therapeutic environment) ₋ Making Agreement (establish time, place and duration of each meeting) ₋ Talking with the Patient (establish mode of communication which is acceptable to both the client and the nurse ₋ Assessing Client needs (Coping Strategies, Defense Mechanisms, Strengths & Weakness). POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 5 3. Working Phase Working Phase Starts when the nurse and the patient can overcome the barriers of orientation and introductory phase. The nurse and the patient actively work on meeting the goals which they had establish during the orientation phase. The end results lead the patient to verbalize, socialize, identify and face the problems realistically. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 6 Role of the nurse (Tasks of Working Phase) ₋ Collects data in detail from primary & secondary sources. ₋ Assist the patient to identify his/her problems and needs. ₋ Help patient to understand that he has a significant role in his treatment ₋ Encourages patient to communicate and use new patterns of behavior and to develop positive coping behaviors. ₋ Explore the patient’s perception of reality and provide constructive feedback. ₋ Develop & implement plan of action with realistic goals, then evaluate the results of action. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 7  Testing of the nurse The patient tests the nurse for their ability and competence. Barriers of Fear of closeness Working The nurse feels that she is working closely with the patient, she may find it difficult to terminate the Phase relationship. The patient may not like to discontinue the relationship. To avoid closeness, she doesn’t communicate freely and makes deliberate attempts to avoid going to the patient. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 8  4. Termination phase  The final step of the therapeutic relationship.  When Nurse and the patient mutually agreed that the goals are reached.  The nurse Discusses the Termination Phase with the client during the Initiation Phase  The nurse encourages to identify the progress that the client has made and explores the necessity of any referral that may be beneficial to the patient.  The client may attempt to prolong the relationship as clinical symptoms of separation such as anxiety, hostility, or sadness are experienced, however, termination needs to occur.  Review the feelings about relationship.  Be aware of Transference and Countertransference. POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 9  Barriers Of Termination Phase  The patient may ask the nurse to write to him or come back from duty and see him.  The patient may ask the address and telephone number of nurse and ask permission to visit her in hospital.  Gift giving POTTER & PERRY, (2013). FUNDAMENTALS OF NURSING (8TH ED.). 10 Assertive Communication in Nursing RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 11  What is Being assertive is important to reduce errors in assertive patient care communicati Creates a trusting relationship between the nurse and patient and between colleagues/ student and on and why mentor is it Healthcare professionals should feel confident to ‫الدعوه‬ speak up when a patient is at risk [advocacy] important in Therefore, it is a core communication skill in nursing which is based on a mutual respect nursing? RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 12 Why is assertive communication important in nursing? It can also help the nurse wellbeing ◦ Reducing stress ◦ Helps you to communicate effectively ◦ Helps you to express yourself ◦ Helps you stand up for your point of view ◦ Can boost your self esteem RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 13 Why assertive communication is needed Being assertive shows that you respect yourself because you're willing to stand up for your interests and express your thoughts and feelings. It also demonstrates that you're aware of others' rights and willing to work on resolving conflicts. Assertive communication is direct and respectful. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 14  If your style is passive or nonassertive, you may seem to be shy or overly easygoing. You may routinely say things such as "I'll just go with whatever the group Passive or You tend to avoid conflict. Why is decides." Non- that a problem? Because the assertive message you're sending is that your behaviour thoughts and feelings aren't as important as those of other people. In essence, when you're too passive, you allow others to ignore your wants and needs. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 15  When rudeness in teams turns deadly RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 16 What do we mean by incivility? ‫الفظاظة‬ When we talk about incivility and disrespect we are talking about a range of behaviours that consists of overt rude or unkind behaviour, micro-behaviours and attitude for example tone of voice, raised voice, rolling eyes, sharp comments, being overtly critical as well as covert behaviours including for example gossiping, undermining and ‫واستبعاد األفراد‬ excluding ‫وتقويض‬ ‫النميمة‬. individuals. THE KINGS FUND 20220 17  Impact of Incivility Building awareness of civility and respect in the workplace and creating opportunities for self-compassion and self-reflective practice will uphold behaviours and values aligned to a restorative approach. Formal awareness/training opportunities are an essential starting point for guided discussion and exploration of both unprofessional workplace behaviours that will not be tolerated and the desired behaviours and commitment to upholding these in everyday practice. ‫ التدريب الرسمية نقطة انطالق أساسية للمناقشة الموجهة واستكشاف كل من السلوكيات غير‬/ ‫تعد فرص التوعية‬ ‫المهنية في مكان العمل التي لن يتم التسامح معها والسلوكيات المرغوبة وااللتزام بدعمها في الممارسة اليومية‬. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 18 Creating a culture of civility Everyone needs to take responsibility for nurturing cultures of inclusion, respect, civility, and for challenging behaviours that are contrary to the team principles ‫أدب‬ ‫يحتاج الجميع إلى تحمل مسؤولية‬ ‫رعاية ثقافات اإلدماج واالحترام‬ ‫والكياسة وتحدي السلوكيات التي‬ ‫تتعارض مع مبادئ الفريق‬ RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 19 Assertive Communication ‘What you say is not as important as how you say it.’ Your communication style is a set of various behaviors and methods of relaying information that impact all facets of life. The goal should always be to understand – not to be right. Get the facts before you pass judgment Learning all communication styles is important to avoid communicating in less effective ways and recognize those styles in others so that you may deal with them. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 20  Assertive Communication Assertiveness : Is the ability to express your ‫ودون قلق ونفقات ال داعي‬ ideas, thoughts, and feelings clearly and openly ‫لها لآلخرين‬. in non-defensive manner, and without undue anxiety and expense to others. Assertiveness : Means being clear about what you need and respectful in your language and behavior. Assertive Communication is: ₋ Appropriate, direct and in expressing one's feelings, beliefs and opinions. ₋ A lifelong skill that requires time and practice. ₋ Being assertive means being able to make requests and refuse unacceptable requests. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 21  Assertive Communication Protecting your own rights without violating the rights of others. The goal of the assertive person is to communicate with respect and to understand each other; to find a solution to the problem. Takes a risk with others in the short run, but in the long run relationships are much stronger. Eye contact maintained; listens and validates others; confident and strong, yet also flexible; objective and unemotional; presents wishes clearly and respectfully. For example: “So, what you’re saying is” “I can see that this is important to you, and it is also important to me. Perhaps we can talk more respectfully and try to solve the problem.” “I think... I feel... I believe that” “I would appreciate it if you...” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 22  Types of Assertion 1- Basic : Express Idea , Belief or Opinion. ‫بدون عذر‬ Example:- “ I want to, I don't want you to, I liked you when you, I had different opinion, I think that I had mixed reaction…”. 2- Emphatic- conveys sensitivity to a situation while taking an assertive position. Example:- ‫بعذر‬ “ I know that the unit is short-staffed, but I have a pressing personal commitment and I cannot work a second schedule. 3-Escalating (Intensifying) Expressing your need more empathetically when a simple assertion didn’t accomplish your goals. ‫تصاعد‬ Example:- “I told you that as a nurse I can’t have a social relationship with you. I must insist that you refrain from asking me personal questions). RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 23  The Advantages of Being Assertive ₋ High probability of getting your requests answered. ₋ Gain respect, People respect clear, open, honest communication. ₋ Gain self-respect when you stand up for your own rights and experience. ₋ You are more independent. ₋ You become a decision maker. ₋ You feel more peaceful and comfortable with yourself. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 24 Learning to Be Assertive: How can we learn it? Saying No Assertively See Pg 255/ 256 for examples of refusing requests assertively Balzer- Riley (2020) RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 25 Clients can be assertive too Getting a second opinion Saying no to medication Right to decline RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 26  Box - 1-2 Assertive Rights 1 You have the right to be treated with respect 2 You have the right to a reasonable workload (Balzer-Riley,2020 Textbook : 3 You have the right to an equitable wage pg. 8; box 1-2) 4 You have the right to determine your own priorities 5 You have the right to ask for what you want 6 you have the right to refuse without making excuses or feeling and guilty 7 you have the right to make mistakes (to be responsible, do not blame other) 8 you have the right to give and receive information as professional 9 you have the right to act in the best interest of the patient 10 you have the right to be human RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 27  Irrational Beliefs: Arise when we are anxious about being assertive and focus on possible negative outcomes. Examples ₋ If I am assertive other people will be upset, hurt by it, or angry with me. Irrational ₋ If someone gets angry with me, I will be devastated. Beliefs and ₋ ₋ Assertive people are seen as cold and self-serving It is wrong for me to turn down legitimate request Rational Rational counterparts: Counterpart Focus on possible positive outcomes. Examples s ₋ The other person may not be hurt or angry ₋ this person might prefer being open and honest too. this person might feel closer to me and help me solve the problem ₋ I would not fold apart in the face of anger. the anger is not my responsibility. an angry response is a choice BALZER- RILEY, J (2020). COMMUNICATION IN NURSING. 9TH ED. 28 ESC : Script to Formulate an Assertive Response Box - 1- Anatomy of an assertive response 4 Framework of for delivering assertive responses is known as the DESC script. Although not all steps are used in every situation it is useful tool. ₋ Describe the Situation. ₋ Express What You Think and Feel. ₋ Specify Your Request ₋ Consequences. Balzer-Riley (2020) Pg 8 Box 1.4 RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 29  Describes a behavior that has a negative impact on the speaker. Example: “When you start shouting, I want to end the conversation immediately.” Expresses a feeling in response to the behavior. Responding Example: “I feel attacked and defensive.” Assertively Specifies the desired change in behavior. Using A DESC Example: “I need you to tell me clearly and calmly what I’m doing to upset Response: you so I can understand my role in this.” Or Specifies the effect the behavior had on you and others. Example: “Your shouting disrupts our co-workers and our ability to focus on our customers.” Consequences if the desired change does not occur (Note: Step 4 is not always possible or necessary and is not only a negative consequence). Example: “or I will ignore you.” or “so that we can work more collaboratively” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 30 How to be Assertive Use “I” statements. Example: “I’d” like to be able to tell my stories without interruption.” instead of “You’re always interrupting my stories!” Use facts, not judgments. Example: “Your punctuation needs work, and your formatting is inconsistent.” instead of “This is sloppy work.” or “Did you know that shirt has some spots?” instead of “You’re not going out looking like THAT, are you?” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 31 How to be Therapeutically Assertive Express ownership of your thoughts, feeling, and opinions. Example: “I get angry when he breaks his promises.” instead of “He makes me angry.” or “ I believe the best policy is to…” instead of “The only sensible thing is to… Make clear, direct, requests. Don’t invite the person to say no. Example: “Will you please…? Instead of “Would you mind…?” or “Why don’t you…?” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 32 Characteristics of Assertive Nurse ₋ Appears self-confident and composed ₋ Maintains eye contact ₋ Uses clear, concise speech ₋ Speaks firmly and positively ₋ Speaks genuinely (honestly), without sarcasm ₋ Is non-apologetic ₋ Takes the initiative to guide situations ₋ Gives the same message verbally and non-verbally. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 33  ₋ It is okay to say, “I don’t know.” ₋ It is okay to say “No,” or “I cannot do that.” ₋ It is okay to make mistakes as long as responsibility is taken for them. What is “Okay” ₋ It is okay to disagree and to verbalize that. in Assertive ₋ It is okay to challenge others’ opinions or actions. ₋ It is okay to not accept another’s opinion as factual or Communication/ accurate (e.g., getting criticized). ₋ It is okay to ask for a change in behavior. Behavior )‫ التعرض للنقد‬، ‫ي عدم قبول رأي شخص آخر على أنه واقعي أو دقيق (على سبيل المثال‬ RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 34  ₋ Allowing our own rights to be violated by failing to express our honest feelings. ₋ The goal of being a passive communicator is to avoid conflict no matter what. ₋ Little risk involved – very safe. ₋ Little eyes contact often defers to others’ opinions, usually quiet tone, may suddenly explode after being passive too Passive long. Example of Passive responses. Communication “I'm unable to stand up for my rights.” “I don't know what my rights are.” “I get stepped on by everyone.“ “I'm weak and unable to take care of myself.” “People never consider my feelings. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 35 Passive Communication Passive Verbal Cues. Effects Passive Gives. “I don’t know.” “Whatever you Up being him or herself think.” Builds dependency relationships “You have more experience than Doesn't know where he or she I. You decide.” stands “I’ll go with whatever the group Slowly loses self esteem decides.” Promotes others' causes. “I don’t care. It doesn’t matter to Is not well-liked. me.” “Yes, yes, yes, yes, yes, yes, yes... NO!” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 36  When the results of pushing the issue would cause problems that outweigh the benefits. When issues are minor. Passive Communication is Appropriate When there is a power differential that is not in your favor and the other party is getting agitated by your assertiveness. When the other individual’s position is impossible to change. (E.g., the law). RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 37  Scenario #1 You’re a nursing student doing your clinical rotation in the emergency department. There has been a care giver that accompanies a patient that keeps following you asking for your number and snap chat. The first time you ignored him, the second time also you ignored him. This is the time that you need to be assertive, what would you do?????? report the incident to your supervisor or hospital security to ensure your safety and to maintain a professional environment. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 38 Scenario #2 You’re a new nursing staff, since day #1 the unit manger has been shifting you night to day and day to night. You’re aware that the schedule should follow 6 weeks night shift then it should switch to 6 weeks day shift. It is your 6 months in the unit, and still this has been a continuous pattern. It is time to be assertive what would you say????? Request a Resolution State the Facts RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 39 Scenario #3 During a home visit you (the nurse) noticed that the patient is unable to make eye contact with the home care giver. You also noticed that the patient is shaking whenever the care giver touches him. You (the nurse) returned to the hospital and filed a report to investigate this issue further. Then after that the nurse manager has called you and threatened to fire you if you don’t withdraw the complain. The nurse manager was saying, “we don’t have time for such things, you need to focus on your work”. How can you respond in an assertive way? Stay Firm on Your Stance: Acknowledge the Nurse Manager’s Position: RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 40  ₋ Protecting one’s own rights at the expense of others’ rights – No exceptions. ₋ The goal of the aggressor is to win at all costs; to be right. ₋ Does not consider actions a risk because this person thinks they will always get their way. ₋ Eye contact is angry and intimidating; lots of energy; loud and belittling; never defers to others, or at least does not admit to; Aggressive manipulative and controlling. Often uses violence or verbal abuse. Communication Example of Aggressive responses “I don’t know why you can’t see that this is the right way to do it.” “It’s going to be my way or not at all.” “You’re just stupid if you think that will work.” Exame “Don’t ask me why just Do IT! What type of communication “Who cares what you feel. We’re talking about making things work here.” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 41 Aggressive Behavior Aggressive behavior is standing up for one's rights in a negative manner that violates the rights of others. Tension and anger are the hallmarks of aggression. The Recipient of aggressive behavior feels dominated, humiliated and embarrassed. The aggressive person blocks the formation of good relationships. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 42 When Aggressive Communication is Appropriate ₋ In an emergency ₋ When there is not time to spend on a ‫حل وسط‬. compromise. ₋ When your opinion is based on several facts, you therefore KNOW you are right, and there is not time to utilize assertiveness skills. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 43  ₋ Forfeiting your own rights initially, followed by manipulation and vengeance later. ‫واالنتقام‬ ₋ The goal of this style is to avoid conflict and then make the other party wish they had seen it your way. ₋ Avoids risk initially, risks relationships later, then acts surprised when people are mad. ₋ Behaves passively to people’s face, then Passive- aggressively when they are sarcasm. ‫السخرية‬ not around. Often uses Aggressive Communication Example of Passive-Aggressive “I love your hair. Most people probably can’t even tell it’s a wig.” “I hear what you’re saying, and I wouldn’t want to make waves, so I’ll do what you say even though someone will probably get sued.” To your face, “Sure I will do it.” Behind your back, “I am not going to do that.” RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 44 What is passive aggressive? RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 45 Passive aggressive example RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 46  Differences Between Assertive, Aggressive & Passive Behavior Assertive behavior: Defending your rights without hurting others. Passive behavior: Individuals disregard their own needs and rights. ‫ يتجاهل األفراد احتياجاتهم وحقوقهم‬:‫السلوك السلبي‬. Aggressive behavior: Individuals disregard the needs and rights of others. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 47  Q1. People who engage in frank and open expression of their feelings are considered a. Aggressive. b. Inconsiderate. c. Rude. d. Assertive Let’s Review Q2. Which type of person is most likely to feel superior to others? a. Supportive. b. Angry. c. Aggressive. d. Assertive RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 48  Every time we decide to communicate with another person, we select a style of communication. Notice yours and notice theirs. Being assertive is not synonymous with an anger management problem – it is protecting your rights without violating others’. Summary Assertiveness allows you to face confrontation in a healthy way and without getting overly emotional. People are not difficult. They only seem difficult to the extent that we do not have the skills to deal with what they bring to the table. It is our lack of knowledge that makes the situation difficult. RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 49  Balzer-Riley, J. (2020). Communication in nursing. 9th Edition. USA: Mosby, Inc. Civility Saves Lives. Accessed online 31/01/2023. At https://www.civilitysaveslives.com/ References Potter, P.A. & Perry, A.G. (2012). Fundamental of Nursing.7th ed.USA: Mosby Elsevier RILEY, J (2012). COMMUNICATION IN NURSING. 7TH ED. 50