Assertiveness is a skill that can be increased by education and training (Rakos, 2003). Learning to be assertive involves not only changes in behaviour but also changes in beliefs about oneself. Self-confidence is an important compo- nent of being assertive. Mastering assertiveness skills helps to reduce the level of interpersonal conflict, which in turn can reduce the impact of stress on the person (Farrell, 2001). The following skills or techniques are essential to assertive interactions in mental health nursing and are illustrated by various examples from clinical practice:
r saying no r making requests.
Saying no
In mental health practice, there will be occasions when the nurse will need to say no to clients, family members, peers and other health care workers. For many novice and indeed some experienced nurses, saying no can be anxiety provoking, particularly about the other person’s response and fear of being re- jected and/or disliked. As a result, nurses often respond by using non-assertive behaviours such as avoidance, being indirect or being aggressive. For example, Agnes asks her colleague Clare if she will swap shifts and work at the weekend.
Clare does not want to change her shift but instead of saying no to Agnes, she indirectly refuses the request by giving a rambling and lengthy answer, stating several reasons why she cannot swap shifts, such as ‘I am not sure if I can work at the weekend, I would like to help you, but I promised I would baby-sit for my sister. She has a little boy, he is three years old. I promised to baby-sit last week but I was unwell. Do you remember, I couldn’t go to your party? My sister never goes out so I want to help her. Did you have a good party? I so wanted to go your party but I was so ill.’ Can you imagine how Agnes might be feeling? More than likely, she feels frustrated and says to herself ‘all I want is a yes or no’. Sound familiar? Alternatively, an aggressive response might be as follows: ‘No I am not swapping my shift for you’ (spoken abruptly and loudly), causing the person who made the request to feel embar- rassed and dismissed. It is important to remember that although we may feel disappointed when someone refuses a request and says no, if the person says it clearly and respectfully, we are more likely to find it easier to accept, and in fact appreciate the clarity provided by the person’s directness.
The principles and practice of saying no
Before the mental health nurse can say ‘no’ assertively, it is essential that she/he internalize the following beliefs and principles about saying no (Dickinson 1982; Burnard 1992). These include the following.
r Permission to say no: Everyone has the right to say no, so just as you have the right to say no to someone, equally the other person has the right to say no to you.
r Separating the request and the person: When you say no to someone, it means that you are refusing or rejecting the person’s request and not the person, for example ‘I don’t want to change my shift.’
r Gut reaction: Learn to notice your immediate gut response when a request is made. This can be a useful guide as to whether or not you really want to say ‘yes’ or ‘no’. For example, if your gut is getting that sinking feeling as the request is being made, the chances are that you really do not want to agree to the request. It is important to be congruent – that is, be true to yourself and the other person. Be aware of the ‘shoulds’ or ‘musts’ that come into your mind and check if they are consistent with what you really want. For example, some of the distorted beliefs that might make it more difficult to say no might include ‘I should never say no to anyone’ or
‘I must always be nice.’
r Taking time: We often feel that we have to make an instant decision and respond immediately following a request. If you are undecided, take time to make your decision, for example ‘I will let you know tomorrow morning if I can change my shift.’ It is also important to ensure that you have all the information you need to make the decision, for example ‘I need to check if there is transport available at the weekend before I can decide to change my shift.’
r Avoid waiting: When you have turned down a request it is common to remain, as a means of offloading any feeling of guilt about the refusal. This can be uncomfortable for both people involved in the refusal. It is best to leave as soon as possible after you have said no, to avoid offloading any feelings of guilt or anger from either person.
r Saying no: When you turn down a request, make it very clear that is what you are doing, preferably using the word ‘no’. Go straight to the point without any padding, and show you mean it by using assertive body language and tone of voice. For example, ‘I have thought about it and no, I do not want to attend the meeting on my own.’ The head, neck and shoulder is upright and eye contact maintained while speaking.
r Broken record: This involves saying the same thing over and over again, using the same volume and tone until the other person gives up, for exam- ple ‘No thank you, I don’t want a cup of tea’, ‘No, thank you I don’t want a cup of tea.’
r Using I: It is best to begin statements using ‘I’ and make them about yourself and your feelings, thoughts, responses, as opposed to saying ‘You’, which can sound accusatory. For example, ‘I am annoyed with you for constantly changing your shift’; ‘I think it’s best for everyone concerned that the client does not go home this weekend’; ‘I blush and feel nervous when the consultant asks me questions.’
r No excuses: When saying no, it is not always necessary to justify your refusal; there may be times however when it is appropriate and help- ful to explain your refusal, as illustrated in the following examples: ‘No, I cannot allow you to leave the ward at this time. You are on Section 3 MHA, which means that you must remain on the ward for the time being.’
Refusing requests
The following are examples of different situations in which the mental health nurse might need to say no to a client, family member/carer or colleague in clinical practice. They are by no means exhaustive or intended to be prescriptive. It is important to remember that body language must also reflect what is being conveyed verbally.
Requests in clinical practice Refusing requests in clinical practice Client: ‘Can I go home’?
Client: ‘Can I smoke in the day room?’
Client: ‘Can I keep my tablets with me?’
Client: ‘Please don’t tell my doctor’
Carer: ‘Nurse, would you like a cup of tea?’
Carer: ‘Can I give my husband extra medication tonight?’
Family member: ‘What made my son take an overdose?’
Family member: ‘You said I could take my son home’
Doctor: ‘I want you to stop Mr X’s wife visiting’
Consultant: ‘Will you witness this ECT consent form’
Social worker: ‘Can you take the client back to his hostel today so that he can collect his clothes?’
Art therapist: ‘Can you stay with the client?’
Nurse: ‘No, you have to remain on the ward until the doctor assesses you’
Nurse: ‘No, there is no smoking allowed in the unit’
Nurse: ‘No, I have to take them.
Medication cannot be kept while you are on the ward. It is the hospital policy’
Nurse: ‘No, I cannot make that promise’
Nurse: ‘No thank you’
Nurse: ‘No, you can only give him what he is prescribed’
Nurse: ‘I cannot tell you that information without his permission’
Nurse: ‘No, that is not what I said’
Nurse: ‘No, I cannot stop her from visiting unless she agrees to this’
Nurse: ‘No, I cannot do that, it is not ethically or legally
appropriate’
Nurse: ‘No I cannot accompany the client, we are short of staff and there is a case review at 11am’
Nurse: ‘No, we have discussed this and it was agreed at the team meeting that he could stay on his own’
Making requests
As a mental health nurse, there will be many situations where you will need to make requests to or on behalf of clients, their families and other work colleagues. It is also important to remember that you have the right to make your own wants/needs known to others, particularly concerning your safety and learning, as illustrated by the following examples.
r ‘I don’t feel confident or competent to carry out a suicide risk assessment’
r ‘I don’t have enough knowledge about the client’s medication to explain it to his father’
r ‘I would like to observe this interview’
r ‘I would appreciate if you would check whether I have recorded the client’s observations correctly’
r ‘I would like to learn how to administer an intramuscular injection’
The best chance you have of getting exactly what you want is by asking for it specifically and directly. When you do not ask for what you want, you deny your own needs and importance.
Making requests involves the following principles.
r Decide what it is you want; for some, this may be difficult and unfamiliar.
One strategy that might assist you with this is to ask yourself what it is you do not want.
r Once you have decided what you want, the next step is to say it clearly and directly.
r Practise making a clear statement or request without using any unnecessary padding, which is often used when we are anxious. Padding weakens your statement and confuses or irritates the listener.
r Avoid asking indirectly or dropping hints – you run the risk of not being heard or understood and as a result your request may go unheeded.
r State what you want succinctly and with conviction.
Stick to it: after stating your request, you may receive a barrage of abuse, a refusal or even be ignored. This is when you move to the next stage, which is to repeat your statement or request calmly until it is understood and acknowl- edged by the other person. The purpose of the repetition is to help maintain a steady position without resorting to manipulative or argumentative com- ments.