Staying Cool Under Fire: How Well Do You Communicate?
By Connie Vogel, PhD, RN, CNE
This course is 1 contact hour
Course must be completed by June 15, 2020
Goals and objectives: The goal of this program is to provide healthcare providers with information about how to manage workplace communication challenges. After studying the information presented here, you will be able to:
  1. Identify three primary communication styles
  2. Discuss ways in which men and women differ in their communication style and stimuli for anger
  3. Discuss strategies to communicate with people who are upset or angry

Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Have you ever been surprised or upset by nasty remarks from a hostile family member? Ever been clobbered by comments from colleagues? How did you react? Were you able to defuse the situation gracefully? Did you faint and fall down or rise up and attack?
When communicating therapeutically with patients, most healthcare professionals in various settings are skillful and confident. However, communicating effectively and comfortably when you are under fire from upset or angry patients, visitors, or colleagues is a challenge you may not be as well prepared to meet. Your resume may focus on your experience with the “hard skills” of providing complex and highly technical care. But experts believe that “soft skills,” such as knowing how to manage the “people” part of your job, have a major effect on job satisfaction and career advancement. The good news is — like other skills — your communication style can be improved with effort and practice.
Your style makes a difference
Working in the healthcare field requires outstanding communication skills. Communication is the transfer of understanding from one person to another. Skillful communication is essential for clinical practice and team building and for maintaining a satisfying work climate. In fact, the ability to communicate effectively is one of the most important areas in which healthcare professionals need to be experts.1 We communicate verbally by using words and tone of voice to transmit information, and we communicate nonverbally through facial expressions and gestures. Although body language is always a vital part of our message, we are usually not aware of it. Thus, we should make sure that our body language is consistent with our verbal message.1 The style in which we communicate has a huge effect on creating understanding. Communication styles often are classified as passive, aggressive, or assertive. A person with a passive communication style appears to be timid, uninvolved, or uninterested. At the other end of the spectrum is the person with an aggressive style.1 People who use an aggressive style are often confrontational and choose words and use gestures that others perceive as sarcastic or even rude. As opposed to the timid, passive communicator and the brash, aggressive communicator, a person with an assertive style communicates in a straightforward and confident manner.2 He or she speaks in a well-modulated tone and augments the oral message by using direct eye contact and appropriate gestures and facial expressions.

Assertive communication involves more than standing up for oneself. Assertiveness is the ability to communicate who you are and what you want and the ability to make others feel they can respond in kind.2
There are many reasons why an individual may not communicate effectively, and even when assertiveness has been developed, there are pitfalls that can undermine effectiveness. Personal variables, as well as internal and external factors. can affect the ability to communicate effectively.3 Giving unsolicited advice; becoming defensive; allowing frustration, helplessness, and knee jerk responses; and blaming others all can sabotage effective communication.3

Although it’s tempting to give advice when another person raises an issue or problem, this advice tends to stop the communication process. It’s often more effective to allow the person to work through the problem by bouncing ideas off a willing and attentive listener.

Becoming defensive is another communication barrier. Being on the receiving end of a hostile message stimulates a powerful defensive response in most people. Rather than mount a defensive, emotional response to a verbal attack, try to recognize that the other person’s communication behavior may be prompted by fear or stress.3

If you find that you are starting to communicate aggressively, look for a physiological or psychological signal that can help you identify your own distress. Stop, take a deep breath, acknowledge that the message was not the one you intended to send, and start over. Learning how to disagree in a calm and rational manner is invaluable in the workplace, as well as in personal situations.3

A sense of frustration and helplessness can develop in unit cultures where problems are not spoken of openly and a team effort is not made to find solutions.3 These units are not pleasant places to work, and ultimately the quality of patient care may be affected. It is unrealistic to expect any team member to solve all problems or rescue everyone in need.

A more therapeutic strategy is to openly bring concerns to the attention of team members and support people as they work through uncomfortable situations with active listening and solicited feedback. Blaming others is another communication stopper.
Saying ‘no’
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THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing Education article.
2.
This continuing education course is FREE ONLINE until December 28, 2018, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/staying-cool-under-fire-how-well-do-you-communicate. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
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If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
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Responding to patient requests is an integral part of a care provider’s role. Healthcare professionals of various disciplines must also respond to requests from many other people, including colleagues, visitors, and supervisors. Requests may range from a patient who asks for your home telephone number or email address to a coworker who asks you to switch days off. Each request is usually seen as reasonable from the point of view of the person making the request. Assessing whether a request is unreasonable is your decision. A request may be considered unreasonable if it interferes with your ability to provide care in a way that is consistent with your ethics and values or if it disrupts your personal life. This is an aspect of setting boundaries that every nurse needs to be able to do.1 In some situations, you must comply with a request, such as a legitimate request made by your supervisor. However, situations arise in which people make demands on your time and skills that you should decline. It’s often hard for care providers to turn down unreasonable requests because our strong need to be helpful can interfere with our right to say “no” clearly and directly. To escape from these uncomfortable situations, we may concoct excuses about why we must say no, and as a result feel helpless and frustrated. At other times, inappropriate guilt feelings about turning down an unreasonable request prompt us to respond in a hostile and defensive way. The middle ground is to learn how to recognize unreasonable requests and how to refuse such requests in a way that preserves your self-respect and also shows consideration for the person making the request. Saying no to a request requires an assertive, rather than an aggressive or passive, communication style.2 When you are assertive, you protect yourself by turning down a request you choose not to handle while at the same time considering the feelings of the other person by refusing in a direct but polite manner.

If you plan to refuse a request, tell the person at the beginning of your conversation. Don’t give elaborate background information and bury your refusal toward the end of your reply. A simple “No, I will not be able to do that” is a clear statement that directly tells the person your intention. If there is a reason that you choose to give, that can be added as a second statement, such as “I won’t have time for that today.” It’s also helpful to communicate that you understand the requestor’s dilemma even if you can’t solve it. If appropriate, suggest an alternative course of action, but don’t communicate that you will take responsibility for coming up with an alternative solution. Don’t convey in any way, verbally or nonverbally, that you are unsure of your response or that with a little more pressure you could be persuaded otherwise. For example, suppose a colleague asks you to help complete her charting because she is behind in her work. A passive (and illegal) response would be to simply comply with her request. A person with an aggressive style might take this opportunity not only to refuse the request but also to lecture your colleague about how she could keep up with her work if she were better organized. A more appropriate way to say no would be, “I’m not able to chart for care I haven’t personally given — but I know you’re running behind.” If you do have time and your own work is completed, you may choose to add “Is there something else I can do to help you catch up?”
Dealing with anger and distress
Today’s hectic and complex healthcare environment has a major effect on the expression of distress in the workplace. Even those with outstanding communication skills may be challenged by difficult situations.3 Aspects of the healthcare environment that can make communication more stressful are patient and family emotions; the nurse’s feelings; contact between nurses, providers, and patients; and the response of the individual nurse to challenging situations.1 A study of how nurses and nursing assistants communicated under stressful and non-stressful situations found that in four aspects (engagement, empathy, task orientation, and loyalty), scores were lower in stressful situations. But in another aspect, creativity scores were higher.9 (Level B) The authors of the study concluded that under stressful clinical situations, nurses were more likely to engage in independent problem solving and be less task oriented and engaged in working with others.9 This study supported other studies that have found organizational factors to be a predictor of stress; these factors include short staffing, role ambiguity, and relationships among staff.9 (Level B) In nursing it is not unusual to be confronted by angry patients or family members who feel that their needs are not being met. Remember that illness or injury is extremely stressful for individuals and their families and that stress may be expressed as anger. This does not make it easier to deal with, however, and learning how to maintain your sensitivity to others and respond in a caring and professional way without distressing yourself requires good listening and assessment skills. “Transforming Nurses’ Stress and Anger: Steps Toward Healing” by Sandra Thomas, a leading nurse expert on anger, provides invaluable advice for nurses about how to recognize and manage anger and other distressing emotions.10 Expressing, suppressing, and calming are the three primary ways in which people manage anger, according to the American Psychological Association.8 Expressing angry feelings in an assertive way is the healthiest way to express anger. A person who suppresses angry feelings can convert them later into more constructive behavior. The down side of suppressing anger is that you may turn the anger inward, causing hypertension or depression, or develop a more destructive way of expressing anger, such as passive-aggressive behavior.8 Calming involves learning how to control both your outward behavior and your internal reactions.8 The instinctive way to respond to anger is to respond aggressively; however, an aggressive response is likely to incite an angry person. When confronted with a request from an angry person, stop what you are doing and listen carefully to what the person is communicating, what he or she is feeling, what he or she is requesting, and whether that request is reasonable.8 Respond with empathy and a sincere tone of voice, validate his or her concern by acknowledging you understand their complaint, stay calm, and remain firm with clear statements of what you are able to do.11 The nonverbal manner in which you respond to a distressed person is as important as the use of appropriate words. It is crucial for the person who is angry or upset to believe that he or she is heard. To convey this impression, stop what you are doing, face the person, eliminate distractions, and give your full attention to the speaker.11 If possible, move to a private area. Do not interrupt a person who is angry or upset; letting the person vent his or her feelings and feel he or she is being listened to can help.
Time is a precious commodity for most practitioners, and the person who is upset may need your attention at a less-than-optimal time. However, taking the time up front to listen to a distressed person is a wise investment because it increases the potential for more-rapid problem solving than if the person is put off or ignored. In dealing with angry coworkers, there are several strategies to get communication back on track. The American Nurses Association has recommendations in the position paper, Violence, Incivility & Bullying, for how individual nurses can respond to anger from coworkers and other members of the healthcare team. The recommendations include taking responsibility for one’s own actions, speaking directly to the other person when an issues arises, being open to other points of view and ideas, and being respectful in talking and listening.12 Following the American Nurses Association Code of Ethics is also an important part of eliminating workplace anger and improving staff relations.13 Staff disagreements are bound to happen from time to time, but they should not be allowed to become disruptive or to result in incivility or any type of abusive behavior. Most healthcare organizations have policies about incivility and bullying in the workplace, often with zero tolerance for such occurrences. Knowing the workplace policy and resources that are available is also an important part of stopping angry exchanges between staff. To defuse a hostile encounter, first try to determine the source of the problem. Focus on feelings as well as facts. Don’t interrupt — when it’s your turn to speak, ask open-ended questions to gain clarity about why the person is upset. Asking an irate person for data can help him or her move from anger to problem solving.8 Ask clarifying questions so you can better understand the reason for the person’s angry reaction. Using “I” messages prevents you from assigning blame; blaming another tends to aggravate a person who is already angry.14 For example, you might say, “I can see that you are angry. Can you tell me what upsets you about what I did?” The next step is to increase the person’s awareness of the negative effect of the hostile communication. Describe your feelings rather than waste energy on evaluating the other person’s behavior. Redirect and reframe, giving some options for how the situation can be addressed.14

An assertive way of communicating this would be to say, “Dr. Brown, you may not realize that you are shouting at me. This is uncomfortable for me and prevents us from resolving this problem. I would be glad to talk to you when you lower your voice.” Remaining calm and in control in an aggressive situation also provides a contrast that may help the irate person realize that the aggressive behavior is inappropriate.11,14 Although responding with one’s own anger might feel good for a few minutes, the fact is that an angry outburst rarely causes someone to change his or her mind about an issue. Take some deep breaths, tell yourself to be calm, and gain emotional control before beginning to address the upset person.14 It is important to set limits on the inappropriate expression of anger.12 If an angry colleague will not back down, you should inform the person that you will not tolerate verbal abuse. For example, you might say, “I spoke to you earlier about the comments you made in the hallway. If they continue, I will report them to my supervisor.”

If you feel physically threatened, walk away from the situation. In patient and family situations, call for security. For help in managing your own anger, talking with a trusted friend may be helpful. Other stress management strategies will also help, allowing you time to calm and cool off.

OnCourse Learning guarantees this educational activity is free from bias. Read the complete CE online.
A Confrontation at the Nurses’ Station
Choice A: “Please don’t talk to me like that. I’m doing the best I can and I doubt the call light was on for 45 minutes because we have a policy of answering call lights within 10 minutes. We’re really understaffed this evening; as soon as a float nurse arrives, I’ll see what I can do.”
Choice B: “You have to understand that when we’re in report, we can’t be disturbed unless it’s a real emergency. You should put her call light on at least 10 minutes before we start report.”
Choice C: “I do care that your sister is in pain, but I have many other patients to take care of, and we really have some sick patients this evening. I’ll ask one of the aides to check on her as soon as possible.”
Choice D: “I can’t be in two places at once. But if you think your sister is in such excruciating pain, I’ll drop everything I’m doing and move her needs right to the top of my list.”
Choice E: “I regret the delay. I know it’s frustrating to wait for someone to respond, especially if your sister seems to be in pain. I’ll meet you in her room in just a few minutes and evaluate what to do about her pain. We can also talk about how to respond to her needs, especially when we’re changing shifts.”
Choice A: This response is defensive and argumentative. The nurse has taken Mrs. Jasper’s comments as a personal attack, and her response does not demonstrate that she has read Mrs. Jasper’s distress level. Debating the length of time the call light was on is likely to escalate Mrs. Jasper’s anxiety level. Stating that the unit is understaffed and there is a need to wait for a float nurse to appear may reinforce Mrs. Jasper’s suspicion that there aren’t enough nurses (or caring nurses) to take care of her sister.
Choice B: This is an aggressive response. The nurse refuses any acknowledgement of or responsibility for a delay in call light response by blaming Mrs. Jasper for not following the “rules.”
Choice C: This is a passive-aggressive response. The nurse states that she does care about Ms. Ingram, but then establishes control by informing Mrs. Jasper that she is in charge of determining in what order patients’ needs should be met. Her response also implies that Ms. Ingram is less deserving of attention because she isn’t “sick enough.” Suggesting that an aide will evaluate her sister’s pain is a patronizing response and may increase Mrs. Jasper’s view that she will need to be more demanding to ensure that her sister receives adequate care.
Analysis: Mrs. Jasper thinks the nursing staff is not responding to her sister’s needs. She is also likely worried about the seriousness of her sister’s injury, her lack of progress, her recent depression, and her prognosis. Mrs. Jasper may be feeling that if it takes such a long time to answer a call light, her sister’s needs are seen as unimportant. The length of time that Mrs. Jasper perceives it takes the call light to be answered also may increase her anxiety about how fast she can obtain help in an emergency. She is making a reasonable request — that you assess her sister’s pain as soon as possible.
Let’s look at the response choices.
You have just finished the change-of-shift report when Mrs. Jasper confronts you at the nurses’ station. Because of a serious fall, Mrs. Jasper’s sister, Nora Ingram, sustained a cervical fracture that, despite numerous efforts, has not yet been stabilized. During the past few days, Ms. Ingram also has shown signs of depression. Mrs. Jasper’s first words to you are, “I need you to come and check on my sister right now! She’s having pain, and I put her call light on more than 45 minutes ago. I want you to come take care of her right now. What kind of nurses are you that you don’t care if a patient is in pain?” Choose one of the following responses.
Choice D: This is a sarcastic response that will likely infuriate Mrs. Jasper and increase the likelihood that she will be a frequent visitor to the nurses’ station. Once the nurse calms down, she probably will regret responding in this way.
Choice E: This is a responsive answer. The nurse acknowledges Mrs. Jasper’s complaint without debating the length of time the call light was on or implying that Ms. Ingram’s immediate needs aren’t important. The nurse clearly lets Mrs. Jasper know that she is being heard. The nurse’s response also sets the stage for future problem solving with Mrs. Jasper.
In nearly every situation in which there is a breakdown in communication, all parties are responsible. But in clinical situations with patients and in professional situations where patient care is affected, it is the obligation of the nurse to find a means to effectively communicate.1,3 Both the sender and receiver of the message are influenced by factors such as emotions, needs, perceptions, education, cognitive ability, values, culture, and noise level.3

You always have control over your response to an uncomfortable situation, even if it is to say, “I can’t discuss that with you right now. I’d like to talk about this later when I have had time to think about it.” Understanding the workplace culture and developing effective communication strategies and self-care are ways identified by staff nurses to improve communication and to enhance success in the workplace for novice nurses.4

Gender differences also affect the communication process. Men and women usually use different communication styles, and these differences can create misunderstandings. Men tend to communicate to reach goals, while women often communicate to establish or maintain relationships. Men are conditioned to use a direct and forceful manner of communicating, in contrast to women, who generally use a quieter and sometimes more passive or tentative approach.5

Interestingly, it is often thought that women talk more in meetings than men, but monitoring indicates the opposite to be true.5 Significant differences exist in non-verbal behaviors between men and women. For example, women tend to nod their head when someone is talking, indicating that they are listening.

Men are likely to view the head nod as agreement, and leave the conversation thinking the woman has indicated agreement when she was merely indicating that she was listening.5 However, it is also important not to stereotype men and women regarding communication. We are each a product of many life factors, both personal and professional, that impact how we communicate.

Communication experts suggest that men need to increase their skills in listening to women who are expressing their feelings and points of view. Women can improve their communication with men when they become more direct, explain the reasons for their views, and become more tolerant when disagreements become part of a conversation.

The emotion of anger, which can range from mild irritation to rage, can have far-reaching negative effects if not managed effectively. Research finds that proactive aggression is higher in men than women; but anger rumination, effort control, and aggression were not different between the sexes.6 (Level B)

There are also differences in what prompts an angry response. Three studies looked at threats to masculinity and perceived power over women as a source of anger.7 (Level B),8 Men who felt a concern for how people perceived them and who felt their masculinity was threatened had more anger and more concern with control over women.7
Given that nursing remains a female-dominant profession at this time, there is certainly food for thought in this finding and its potential effect on interactions with male staff members and on interdisciplinary interactions with other healthcare professionals.
Learn how to keep your head in heated situations
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EDITOR’S NOTE: Maureen Habel, MA, RN, past author of this educational activity, has not had an opportunity to influence this version. Connie Vogel, PhD, RN, CNE, is an experienced psychiatric nurse and the author of a number of continuing education programs on psychiatric nursing, mental health, and communication strategies. She also is online faculty at Capella University School of Nursing.
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