Communication is an integral part of our day-to -day life which not only help us to share or transmit knowledge, but also help us to contextually relate to other human beings. Human beings use several forms of verbal or non-verbal communication to express numerous emotions. Robust communication skills are required for a harmonious personal life as well as a successful professional life. Though, strong communications skills can help an individual to excel in any profession, but these prove to be a pivotal set of skills for some professionalsviz. healthcare or nursing. Among all the healthcare professionals, nurses are the only team member who interact with almost all stakeholders of the healthcare team. Through effective communications nurses bridge the gap between patients and doctors(physicians). Nurses are anticipated to judge the situation and use apt set of communication framework while having staff to staff interactions across disciplines, units or hospitals; staff to patient communication; and staff to family/carer/advocate communication.
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The present paper deliberates one such important communication framework i.e. assertive communication which is used during nursing communications. The paper uses a hypothetical scenario as an example to explain the basic concept, strength and limitations, and application strategies of assertive communication in nursing. The paper also critically analyses the necessity of using assertive communication in the chosen scenario.
Assertiveness is the ability to express one’s feelings, opinions, beliefs, and needs directly, openly and honestly, while not violating the personal rights of others (Ellis & Hartley, 2005). Traditionally, it was believed that a nurse should be acquiescent and submissive while communicating with the doctors/ patients/ family/caregiver (Slater 1990; Poroch & McIntosh 1995). But, over the period of a paradigm shift has been observed in nature of nursing profession, healthcare laws, and legal rights of nurses (particularly female). These changes in the healthcare scenario compel the nurses to explore other sets/ frameworks of communication, assertive communication being one of them. Being assertive doesn’t imply to be aggressive or rude while communicating. Rather it means to voice your opinion in a positive way by staying calm and standing for your or other people’s right. Though in some people assertiveness comes naturally, yet some need to learn it by practice and application. There are basically two model which can be applied for practicing assertive communication in nursing. First one is “See it, Say it, Fix it”, this implies to looking into the situation and critically analysing it, thinking analytically about what should be communicated and saying it, and working together with the other person to resolve or fix it. Another model used for applying assertive communication is a descriptive version of three-step model explained earlier and is known as the “Five-step model”. This model uses a five-step approach to resolve the problem and effectively communicating the message: getting other person’s attention, expressing concern, being direct and unambiguous while communicating, stating the problem and explanation (if required), proposing a plan of action, and reaching to the right decision by positive discussion.
For example, in the chosen hypothetical scenario, a nurse was advised by the team members to communicate with the family/friends of a young man who is brought to hospital unconscious with serious head injuries. The nurse is supposed to inform the family that the patient is unconscious and needs to be shifted to intensive care unit for further management. However, the family responded aggressively for the delay in information and invaded the personal space of the nurse by poking on shoulder. In current scenario, being passive and accepting the aggressive behaviour of the family members could create a havoc situation which could negatively affect the self-esteem of the nurse. As quoted by George Bernard Shaw “the greatest problem in communication is the illusion that it has been accomplished.” Being passive in such scenario might give an impression of having empathy with the family members, but it could give a wrong message of negligence on part of hospital and healthcare team. Passiveness or lack of assertive communication skills in nurse are often picked up as inferiority complex (O’Mara 1995). However, assertive communication in such scenario reflects a direct, open and honest explanation, which clarifies one’s needs to the other person. Hence, in such scenario an assertive framework of communication is required.Burnard (1992), also stated that assertiveness depicts professional confidence among nursing professionals and should be encouraged.
In the current scenario, it is recommended that a nurse should apply a five-step model of assertive communication framework. Direct and clear communication is one of the important element of assertive communication. It is important that the nurse stay direct in the communication with the family members of the patient. It is necessary that the nurse call them by their name (if not known, may ask first whom he/she is speaking too). This generate a feeling of acquaintance with the family, and gives an impression that nurse is well-acquainted about the patient. Using indirect ways to address gives an impression of lack of knowledge about the patient. Second important thing is maintaining the eye-contact while talking with the family. This shows confidence in the communication. Choice of words is another important aspect. The message delivered to the family should be clear and precise in a language understandable to them. Try not to use too much medical vocabulary or jargons, as these might create confusion in the family members. It is also required that a nurse explain the further plan of management, why it is required for the patient, and how the healthcare team will execute it to the family. A nurse should always ask for a feedback once the explanation/ information is provided to the family. This reduces the chances of misinterpretation.
The second element of assertive communication is being apologetic about any delays or inconvenience caused by healthcare team or their counterparts. As described in the scenario chosen, the family is already furious about delay in information about their patient. So, in such case it is necessary that the nurse empathise with their situation and provide them legit explanation about why the information was provided late to them. It is advised that a nurse should not built up any lame stories to coverup the mistakes by the healthcare team in delaying the information to the family. Rather, in such case it is required that a nurse accept the fault on the counterpart and give a genuine explanation the delay.
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The third most important element in assertive communication framework is to understand the rights and voice your opinion. It is necessary for a nurse to understand that being accepting and subservient is not part of the job responsibility. It is required that a nurse should stand for his/her self-respect and self-esteem. Invasion of personal space, even though by a grief stuck family members should not be accepted. As described in the hypothetical situation, the family member invaded the personal space by poking on the shoulder. Hence, under such situation, the nurse should express the uneasiness caused in a firm voice, explain that such gestures are unacceptable, and if require warn the family member of strict action if this kind of behaviour is repeated. Even though, such communication is required in such situation, yet most of the nurses refrain from using assertive communication. As concluded by Valentine (1995), nurses believe that they are expected to resolve a conflict by caring and interpersonal obligation rather by voicing their rights.
It is required that the nurses understand that assertiveness is ability to express one’s feelings, opinions, beliefs, and needs directly, openly and honestly, while not violating the personal rights of others. As seen in the hypothetical scenario used it is need of the situation to be assertive. By openly expressing the discomfort against invasion of personal space and honestly explaining the cause of delay in providing the information about the patient to the family members should not be considered as aggressive behaviour. Rather, clarity and straight-forwardness in the communication will help the nurse in developing strong interpersonal relations with the family members. Peplau, 1997 also stated that interpersonal relations are important in nursing.Establishing a trusting interpersonal relationship allows nurses to make suggestions, communicate openly with patients and family members and be assertive in the patient care.
Another important aspect of communication in this scenario is the clarity of the communication. Family members of the patient who are not well-informed often develop anger against the healthcare staff anticipating negligence on their part. Hence, it is important that a nurse bring out a clear communication with the family member. A nurse should clearly explain the events as they have happened once the patient has been admitted to the hospital. The exact procedures which are carried out and their relevance for interest of patient health. It is also necessary that the nurse have a clarity while briefing the next steps which are planned for the patient and hoe they will be executed. A clear explanation from nurse will help the family member to gain confidence in the healthcare team and the management strategies planned for their patient. It is also vital to gain consent from them regarding medical procedures.
Nurses are a very resourceful member of the health care team, they are efficient in drawing variety of physical and psychological intervention that facilitates management of the patients and provide empathy to the care providers. However, it has been observed that nurses are often type casted in terms of their behaviour and communication, and are anticipated to communicate in a defined. With changes in time and trends of healthcare and expansion of job responsibilities of the nurses, it is required that nurses understand the requirement of different sets of communication skills like assertive communication. It is necessary that the nurses understand that being assertive boosts their communication skills and help them to grow as a professional. Various nursing literature have repeatedly called for teaching assertive communication skills to the nursing students as part of early learning, as well encourage them to practice by role play or in real life situations. It is required that all nursing professional should understand that being assertive is not equivalent to being aggressive, rather it is a sign of self-confidence, believing in your work, and standing for your opinion.
From this report, it can be concluded that communication play vital role in order to develop trust and confidence within the patient and their family members. In accordance with the case, a patient was bought to the hospital with head injury and got unconscious. Their family members where waiting for long time in the waiting room. They are really upset for not providing them proper information regarding what had happened to the patient. As per the situation, it is important to have assertive communication that will enable to convey the information. Further, there are two models for practising assertive communication. Among the two, five steps model is taken into consideration. Further, it is essential to have proper eye contact and to deliver information by stating their name. This is helpful in conveying the information and to make their situation under control.