Setting limits, asking for help, delegating, or even saying “no” are important assertiveness skills. Health care professionals should be proficient in assertiveness because of the potential impact on patient safety, patient experience, workforce health, and cost-effectiveness.

Assertiveness examples

How might these assertive statements influence outcomes?

• “I haven’t had training in using that IV pump and need help.”
• “Stop! Don’t make that incision! It is the wrong leg.”
• “I cannot keep seeing patients at this pace and feel like I am doing a good job.”
• “I need more time with Mrs. Smith before she is discharged. She is expressing fears about her colostomy.”
• “I need proper PPE before going into that room.”
• “I can’t help you right now. I need to get Mr. Jones’ pain meds. Maybe Sally can. I just saw her come in.”
• “Please step back and out of my personal space.”

Do these seem like reasonable, professional statements in the culture you work in?

Danielle Ofri, MD, makes this compelling point about assertiveness in her New York Times op-ed piece, “The Business of Health Care Depends on Exploiting Doctors and Nurses“: “One additional task after another is piled onto the clinical staff members who can’t—and won’t—say no.”

Can’t vs. won’t say “no”

Why can’t or won’t we say “no”? For many of us, such statements can feel emotionally risky. We may be afraid of being wrong, worried we’ll be judged or rejected, and/or fear job repercussions. All of these may be real possibilities.

Furthermore, hearing “no” may be unwelcome by leaders who are juggling limited time, money, staff, etc. In the short term, this may seem understandable given limited resources; however, in the long term, it promotes a culture of poor communication and can contribute to significant problems!

People who can’t or won’t express themselves in healthy, assertive ways will find other passive-aggressive, aggressive, or passive ways. Quiet quitting, burnout, bullying, withholding information, and working unsafely are costly examples.

Alternatively, a culture that supports dynamic speaking up and listening, staff will contribute to creative problem-solving, reasonable, safe compromises, and efficient and safe use of resources.

With our patients’ lives, our lives, and the health of the system all on the line, it is important to promote assertiveness among health care professionals. One approach comes from the world of applied or medical improv.

Using YES AND for NO!

In a recent KevinMD article, I discussed YES AND as a powerful teaching tool for health care leaders. It is the golden rule of all improvisational activities. It basically means you accept what another person says (the YES), and you add something to the scene or story (the AND).

Consider two improv conversations:

Person 1: There is a big hole in our boat. Person 2: YES, there is a big hole in our boat.

In the above conversation, Person 2 is validating Person 1 and following a “say YES” philosophy. (Great for developing and practicing listening skills!) What makes this next conversation different?

Person 1: There is a big hole in our boat. Person 2: YES AND let’s get to that island STAT!

The second conversation involves confidence, ownership, and risk-taking on the part of Person 2. All of which can feel emotionally risky to someone who is developing assertiveness. Deep down, such risk occurs in the same emotional place one may be afraid of being wrong, judged, rejected, or fear job repercussions.

Asking questions is a common tendency for people developing assertiveness and/or working in cultures that don’t support the skills. Instead of sharing an idea, they defer responsibility to their partner.

Person 1: There is a big hole in our boat. Person 2: What should we do?

This speaks to subtle and powerful teaching opportunities that improv offers. As a facilitator, I can coach a person to make a statement and not ask a question. And while emotional risk is certainly present, it is safer than in the middle of a clinical crisis. Leaders can draw insight from this example and be on the lookout for questions where deferring accountability might be going on and simply ask, “What ideas do you have?”

Try it!

Experience is the best way to gauge how complex the learning can be. What could you say, and how might you feel on the spot?

Person 1: There is a big hole in our boat. You: [Your response here]

What did you come up with? Did you have ideas for fixing up the hole? Did you jump out and find the water was only a few inches deep? Did you call 911?

Was it easy? Did you notice any hesitation?

Summary

Setting limits, asking for help, delegating tasks, and saying “no” are important communication skills for health care professionals. They can be challenging to develop and practice in health care settings. Individual skill deficits and/or organizational culture are contributing factors. Medical or applied improv can help!

Beth Boynton is a nurse consultant and author specializing in research, training, and writing about emotional intelligence, communication, teamwork, and complexity leadership. She’s a pioneer in developing medical improv as a teaching modality for health care professionals and the founder, Boynton Improv Education. Find out more about upcoming open events, videos, and articles related to medical improv. She can also be reached on Facebook and LinkedIn.