Not too long ago, I was speaking to over 100 WSNA nurse leaders in Washington State. While standing there with my microphone, power point, and some anxiety, I shared a story about asserting myself re: a staffing and safety concern I had experienced two weeks earlier in my per diem role as a staff RN. “I have a graduate degree, have written a book, and have been a nurse for over 25 years and yet taking my concern to my supervisor, the scheduler and ultimately the Director of Nurses, was harder for me to do than stand in front of you giving my first Keynote Address today”!
Changing behavior is hard! Sometimes very big problems seem to have simple solutions, at least from an intellectual standpoint. But, do they work?
Just say “No” to drugs.
Stop eating so much sugar and fat!
Practice ‘Safe Sex’
There is a lot of great information in The Joint Commission’s webpages on their award-winning ‘Speak Up’ initiatives, but I do take issue with advice that tells us ‘Don’t be afraid’ or ‘Don’t be embarrassed’. Telling us how we should feel serves to oppress assertiveness rather than build it! We need to know how we feel and have a sense of safety and honor around it. If we look deeper into the challenges of developing assertiveness we can see how both individuals and organizations can help.
What Makes Assertiveness Harder than it Looks?
Assertiveness involves personal growth in such self constructs as; self-respect, self-esteem, self-efficacy. These are core and powerful beliefs we carry from our life experiences, culture, and genetics. Even when we embark on personal work to evolve these ‘skills’, or develop emotional intelligence, it can take years of practice and a willingness to take risks that may indeed feel very scary. When a patient with low self esteem considers reminding a doctor to wash his/her hands, the patient may literally have to struggle with risking a hospital acquired infection or confirming deep-seated beliefs that he/she is not worth safe care. Or consider the nurse who believes that her/his comments , (“That’s the wrong leg, Dr. Smith!) will not lead to a change in the surgeon’s behavior, but more likely lead to humiliation in front of the team. Due to past experiences in her life and possibly with this surgeon, she/he may hold back . The consciousness involved in either situation may be fleeting, yet both of these options may threaten some aspect of survival! Telling people, “Don’t be afraid”, is an oversimplification that allows us to think we or appear to have addressed the problem.
What we really need to be asking as healthcare leaders is, “How can we help you to feel safe reminding us to wash our hands?” Perhaps nurses could state during the admission process, “I’ll try to wash my hands but I am very busy and may try to skip this step or even forget. Please feel free to remind me!” And similarly, the surgeon can tell the surgical team, “I’m in charge and depending on you. If you see me making a mistake or even think I might be about to, I want to hear from you right away!” And then listen respectfully. This means nurses, physicians, and all staff have the time and skills to to do so. Telling folks to speak-up and then not listen is a fatal flaw and likely to lead to shutting up or aggressive behavior. (Check out this Swiss study about docs and nurses resistance to patient assertiveness about handwashing.)
What Does Effective Assertiveness Training & Promoting Look Like?
Effective assertiveness training goes beyond teaching the guidelines of listening or assertiveness language. We must ensure that a safe environment is created for learning and coaching opportunities with real world scenarios are offered. Workshops like these are typically longer and smaller in size. The facilitator becomes a familiar and trusted resource for personal and group risk-taking in developing new behaviors. In addition, organizational leaders should recognize that there will be a learning curve for practicing the skills under stress, (which is pretty much constant). Creating opportunities for practice such as during Grand Rounds or at staff meetings, evaluating efforts and seeking improvements, rewarding successes, and role-modeling giving and recieving constructive feedback. Teaching these soft skills involving behavior change does involve a baseline of intellectual knowledge, yet learning will continue with new real-life experiences and increasing trust.