Beth Boynton, RN, MS specializes in communication, collaboration, and workplace culture. She offers advice on how to navigate common conflicts in nursing and healthcare with an eye towards shared accountability and co-creative solutions.
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I am a staff nurse on a med/surg floor. I’m trying to develop assertiveness and am hoping you will have some ideas for this situation. There is one physician who is very difficult to deal with; she tends to mumble sometimes and yell at other times.
This doctor has yelled at me a number of times during phone conversations and sometimes in person. I feel shaken after such interactions and it makes an already stressful job even more stressful. I dread taking care of her patients because I don’t want to deal with her. I’m not the only one, either; we all cringe when we hear her voice on the unit.
One recent example was when she was giving me orders over the phone for a new IV antibiotic for a patient, and I couldn’t tell whether she was saying “clarithromycin” or “erythromycin”. I asked her to repeat it once but I still wasn’t sure. When I repeated the wrong order back to her, she yelled at me and accused me of not paying attention.
She and I have both worked in the same area for several years, and I wish things were less stressful and more collaborative between us. Any suggestions?
Wishing for Respectful Collaboration
Thanks for a super topic to explore, and for expressing such a wonderful wish! Assertiveness is so important and yet can be more complicated than it seems.
Individuals often need to develop stronger self-esteem and be more accountable for their words and actions; both can feel emotionally risky since they each require assuming more power and personal agency. This can be scary if we lack confidence; it can also exacerbate other insecure feelings (eg: being uncertain whether we’re right, or worrying about someone judging us). In addition, the workplace culture needs to be a safe environment for speaking up.
A confident person in a safe culture will feel comfortable saying, “I don’t know,” whereas a person with low or fragile self-esteem working in a culture where blaming or bullying exist may feel intimidated. For better or worse, this combination of individual and organizational behavior are ongoing and interrelated phenomena that impact communication.
I’m always amazed at how powerful some toxic behaviors are and how unaware some professionals are of how their behavior impacts others. In my classes or workshops on organizational conflict, communication, and leadership, there always seems to be one or two notorious people; everyone in the organization knows them. They may be physicians, nurses, or administrative leaders; they may have a tendency towards aggressive or passive-aggressive behaviors, and no one knows quite what to do in response. Generally, such individuals constitute a relatively small number of people with a disproportionate amount of power.
Let’s consider some potential opportunities for practicing assertiveness in this scenario.
Addressing the mumbling
Assertiveness is a valuable skill, and when we are adept at, and supported in, being assertive, there are many opportunities for personal growth. For instance, during the call, you can clearly say:
Dr. Smith, I can’t tell whether you are ordering ‘clarithromycin’ or erythromycin’. Please clarify which of these you want.
Addressing the yelling
Yelling is usually an aggressive and ineffective way to communicate. It is hard to be assertive in an aggressive situation, especially if there is an unequal power dynamic with a physician or supervisor. Nevertheless, we are undergoing a sea change in healthcare, and difficult steps are necessary in order to eliminate this form of ineffective communication from the healthcare work environment. For instance, during the call, you might say:
Dr. Smith, please stop yelling at me; it is inappropriate and I can’t understand you. Please lower your voice and tell me what you would like to do for our patient.
A similar approach could be adopted during a face-to-face incident:
Dr. Smith, stop yelling at me; it is inappropriate. Please lower your voice and tell me what you would like to do for our patient.
In addition to using a clear and firm voice in all of these examples, your body language for such a face-to-face confrontation can make a difference. One type of body posture that I find helpful if someone is invading my personal space is called the “mediator’s stance”. To do this, pivot slightly to the side and bring both arms up, elbows slightly bent and palms at an angle as if to say “stop.” This defines your personal space without blocking the aggressive person; in a sense, you get out of their way and still maintain a non-defensive, non-threatening, and confident posture.
If no one has ever given Dr. Smith this kind of feedback, she might be surprised and willing to work with you and others; there is no guarantee, but she deserves the opportunity!
Addressing the chronic dynamic
Depending on how safe you feel, there is an opportunity to provide some feedback to this physician, build a relationship, and set limits for future interactions. I think you have all of the information you need to initiate the process and, with a little reflection, could offer a lifelong gift to the doctor.
You might start out a conversation thus:
Dr. Smith, I have a concern that I would like to talk with you about regarding our communication. Would you be willing to sit down with me privately for 5 or 10 minutes later today or some time soon?
Once the two of you agree on a time and place, you might start out the conversation something like this:
Thanks for meeting with me. Dr. Smith. I’ve been learning about assertive communication and its importance in patient safety and workplace culture. I’ve realized that some of our interactions over the years have had an unhealthy tone; I’m specifically talking about phone and face-to-face conversations where I have perceived you to be either yelling at me or not speaking clearly. I find now that I dread having to communicate with you and I know that this is not professional or realistic. I’d like us to be communicating more respectfully; what thoughts do you have?
She may or may not be receptive to this, and only you can gauge whether you feel safe enough to take any of these steps.
Addressing the culture
It is important to note that the organizational culture plays an extremely important role in creating and sustaining a culture of safety in which nurses can develop and practice their assertiveness. How nurses communicate will influence the culture, and the culture will influence how nurses communicate.
As you learn about assertiveness, look for opportunities to observe, practice, and model behaviors that will help you and others develop it. Culture change is hard work that will benefit from long-term leadership commitment, yet one nurse having one conversation with one doctor can help change the status quo.
Thank you for writing. Taking the initiative to reflect on and consider addressing a chronic problem like this takes a lot of courage. I hope these ideas are helpful; if you decide to act on any of my suggestions, please let us know how things go – and good luck!
Next Up: Overheard A Mean Conversation!
Beth Boynton, RN, MS is a Medical Improv Practitioner and author of Confident Voices (CreateSpace 2009) and Successful Nurse Communication (F.A. Davis 2015). Her third book, Medical Improv: A New Way to Improve Communication is scheduled for release in 2017.