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We’re joined by Beth Boynton, a nurse consultant and author, to discuss the critical role of assertiveness in health care. Explore how assertive communication influences patient safety, workforce well-being, and more. Join us for actionable insights and practical tips to enhance your assertiveness skills in the health care setting.

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.

She discusses the KevinMD article, “Empowering health care professionals: the art of saying ‘no’ and more.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Beth Boynton. She’s a nurse consultant and a pioneer in developing medical improv as a teaching modality for health care professionals, and she’s the founder of Boynton Improv Education. Today’s KevinMD article is titled “Empowering health care professionals: the art of saying ‘no’ and more.” Beth, welcome back to the show.

Beth Boynton: Thanks, Kevin. It’s really nice to see you. Hi, everybody.

Kevin Pho: So we’ll get into your article in a little bit, but for those who didn’t listen to our first episode together, just briefly share your story.

Beth Boynton: I’ve been a nurse for over 30 years, in home health, occupational health and long-term care. Around the turn of the century, I got a master’s in organization and management, which was around the same time the Institute of Medicine was publishing reports on the errors we were making and how they were related to communication. I started developing a consulting business to teach soft skills, so I’ve been teaching, writing about and researching communication-related skills for the last 20 years. That includes writing two textbooks for nurses on communication, co-authoring one on complexity leadership, and writing the industry’s first book on medical improv.

Kevin Pho: All right, so we’re going to talk about your KevinMD article about assertiveness. It’s titled “Empowering health care professionals: the art of saying ‘no’ and more.” I think this is very relevant, because sometimes we in health care have trouble saying no, and I think that leads to a lot of the burnout issues we face. How did your article come together?

Beth Boynton: Well, I think it’s just because I’ve been teaching these skills for so long. I’ve been following and researching the sentinel event data, and the data on the mistakes we make consistently show that the underlying problems are communication and human factors. So there’s this ongoing, pervasive and persistent problem with communication, and the question is whether we are getting at the underlying issue. I think part of that goes to some of my personal journey: learning to be an assertive person in my life, and how difficult that was in health care. I started to get the skills, but boy, they’re hard to practice in a culture where those skills are not supported.

Kevin Pho: So give us an example of the need for these skills in health care professionals. Give us an example of how health care professionals sometimes have trouble saying no.

Beth Boynton: Well, I guess there are two parts to that question. An example of when we don’t would be anytime we have a sentinel event and somebody didn’t speak up, even though they had an inkling. Maybe that patient was allergic to something, or maybe it wasn’t the right patient for that surgery. They may have thought it, but they didn’t have the presence and confidence to say, “Wait a minute. I think we’re going to make a mistake here.” So those are examples of what happens when we can’t say no, from a patient safety standpoint.

But to your point about burnout, it’s also this: If I don’t say, “I am too tired,” if I don’t have the awareness to know that my own fatigue is setting in, then that’s going to lead to mistakes, number one, but it’s also going to lead to my burnout, as well as to that of a colleague who may be struggling. It’s our ability to speak up for ourselves, as well as to support each other when we’re saying, “I can’t do something,” or “I need help.” It’s almost like there’s this invisible message that you can’t say that, that it’s going to be somehow humiliating, or you’ll face rejection, or you’re not good enough. And it’s a vicious circle.

Kevin Pho: Let’s talk about those two scenarios. The first one you mentioned is speaking up when it comes to a patient safety issue. As you know, medicine and health care are very hierarchical, and people who are not higher on the hierarchy chain have trouble speaking out, or there may be implicit pressure not to speak out. Tell us how you can help people in that scenario.

Beth Boynton: I think number one is to realize how hard it is. Just asking the question gives some sense of that. The other thing, I think, is that people need to have opportunities to practice speaking up with their peers in a safe environment, because the idea of speaking up can involve some emotional risk. Trying to do that in a culture with constant, relentless, high-stakes, high-pressure work, that’s the last place we’re going to take an emotional risk. We’re going to do what’s familiar, which might be to freeze or shut down or run away, but that’s not the way to learn how to speak up.

Kevin Pho: Now, when you say this has to be practiced, and you’re an improv educator, do you recommend role-playing? What are some exercises people can do to practice speaking up in those situations?

Beth Boynton: Role-playing is certainly one helpful technique, and we’re seeing that with sim programs. I actually like to go into a deeper place, with even very simple improv activities that aren’t clinically based at all. They’re really just based on the actual practice of developing confidence. Because of the way improv works, if I speak up in a supportive environment, I’m going to have a new experience of speaking up, and I’m also going to have the experience of being heard and affirmed. Those two things help to build the self-confidence, and the trust with peers, to take those risks.

Kevin Pho: Is there a success story where you implemented some of those techniques with a particular individual, and you could really see how it changed their confidence and led them to speak up in a health care setting? Do you have a success story you could share with us?

Beth Boynton: I usually get feedback weeks or months after an event, where somebody will say, “Oh, thank you so much for that ‘yes, and’ training, because I shared an idea in a meeting, and it was heard. We’re going to try it.” Another example that sticks with me is this. There’s an activity called same-time story, or story mirror: One person tells a story, and the other person tries to follow it at the same time. It’s kind of hard to do and awkward at first. I guess I don’t need to go into the details, but a nurse told me after that activity that it was the first time she had ever felt heard. And it’s like, what? Wow. If she didn’t feel heard, how is she ever going to be a good listener? So to me, that was a stepping stone.

Another example I can think of was with a group of risk managers. We just did a “yes, but” versus “yes, and” example, and the president at the time, who has since retired, said, “Wow, that’s why we have so many communication problems in health care.” So the awareness that can come from understanding the nature of why people don’t speak up is pretty powerful.

Kevin Pho: I know that the “yes, and” technique is a cornerstone of improv. For those who aren’t familiar with it, just give us a brief synopsis of the “yes, and” technique.

Beth Boynton: Sure. There are lots of different activities, all based on that principle. The “yes” means you’re agreeing to say yes to what your partner says. If you were to tell me that there is a plant on my head, I would say, “Yes, Kevin, I’m trying it out as a new fashion statement,” or something. I say yes to that, and the “and” is why I have a plant on my head. So we have this agreement: “Yes” to what you said, “and” I’m going to add something to it. That seems really simple, but if we put it under the microscope, and I’ll try not to go too far off track here, the things that can be learned from “yes, and” involve emotional intelligence, communication, teamwork and complexity. Even attunement can happen with “yes, and” activities, and we’re hearing a lot about that in trauma-informed research.

Kevin Pho: So I want to get back to the second scenario we mentioned earlier, about a clinician who’s asked to do too much. It could be a primary care doctor asked to participate in another after-hours activity, for instance, who may not have the assertiveness to decline that opportunity, and saying yes to something like that may contribute to their burnout. Tell us how you can help in that scenario, in terms of declining or saying no to opportunities that may be leading to burnout.

Beth Boynton: It’s actually the “and” part that can help us with that. We learn a lot about listening to others, and yet the “and” helps us become aware of what’s going on with ourselves, as well as to honor that. So even with a very simple activity, where we name things and a group affirms them, we get the experience of saying something instead of freezing. I would like it to be more like a switch you turn on and off, but it’s really a step in the direction of building the emotional intelligence so people can have confidence in what they’re feeling, identify it and take the risk of saying, “I can’t.”

Ultimately, that gives other people a chance to say, “OK, well, I could do a little bit extra this week.” Or maybe a leader is going to say, “Well, you’re always saying no, so that’s not going to work, because there’s an expectation that you’ll be a team player.” But we can have those conversations, instead of the ones that lead us to shut down, get burned out or get injured. Or maybe we say yes but resent it, so we’re irritable with other people, and it becomes more of a contributor to a bullying culture.

Kevin Pho: So you mentioned the word “culture,” and I wanted to explore that in a little more depth. How much is the lack of assertiveness that sometimes occurs in health care professionals associated with the culture of a particular workplace?

Beth Boynton: I think it’s a very significant part of it. When I was first practicing as a nurse, I was a pretty assertive person, but it didn’t take me long to shut down, because it’s sort of like getting invisible feedback. We have cultures that will often say, “Well, yes, we want you to speak up for your patients or their families,” but don’t speak up for yourself. Don’t ask for more help or more staff, or about extra overtime. Those things are not encouraged, which is actually kind of a mixed message, and people shut down. If you don’t have a healthy way to communicate, then you do something else, and none of the alternatives are really healthy ones.

Kevin Pho: Now, ideally, in order to enact culture change, it would come from the top down, from health care leadership. Are there stories where we can change cultures on an individual basis, from the ground up? Have you heard stories like that?

Beth Boynton: Well, I believe in it passionately. As one nurse or one physician, we may not be able to have that huge impact, except that if we reach our limit and leave our jobs, then we go someplace else, and that’s not an ideal scenario to paint. I believe it has to happen from the bottom up and the top down. It’s almost like: Can we have a collective voice in health care without forming a union? Not that I’m against unions. I just wish we could have respectful dialogues about what we need in order to do our jobs safely, for our patients and for ourselves.

Kevin Pho: We’re talking to Beth Boynton. She’s a nurse consultant and a pioneer in developing medical improv as a teaching modality for health care professionals, and she’s the founder of Boynton Improv Education. Today’s KevinMD article is titled “Empowering health care professionals: the art of saying ‘no’ and more.” Beth, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Beth Boynton: I have three. One is that cultivating effective, respectful communication will help with every single outcome we are trying to accomplish: safe care, a healthy workforce, the patient experience and even cost. The second lesson is that speaking up can be really hard to do. You don’t just snap your fingers and say no; people need practice opportunities to develop the skills. And third, “yes, and” improv activities, even on a small scale, can be helpful.

Kevin Pho: Beth, thank you so much again for coming on the show and sharing your perspective, time, and insight.

Beth Boynton: Thank you very much, Kevin.