Asertiveness Skills

PROFESSIONAL DEVELOPMENT
Assertiveness: making yourself

heard in district nursing
Sally Lawton, Fiona Stewart
Sally Lawton is Senior Lecturer in Nursing - Palliative Care, Roxburghe House, NHS Grampian, and Fiona Stewart is
Manager, Simulated Patient Programme, Medical School, University of Aberdeen Email: sally.lawton@arh.grampian.scot.nhs.uk
nteractions with colleagues occur in many different

situations: managing or being part of a team, implementing or being required to implement change, delegating and receiving delegated tasks. Any of these situations may give rise to tensions. In this article, we aim to
highlight certain difficulties with colleagues that can arise
through an inability to assert ourselves in an appropriate
and effective manner.We will also look at ways in which
we can change our behaviour.
The outcome of an exchange with a colleague can
leave us feeling dissatisfied, abused, impotent or even
guilty. Feelings of impotence can result through the frustration of having acquiesced to an undesirable outcome.
Guilt can be the result of being overly forceful or inappropriately aggressive to achieve a desired outcome.
In short, if we have achieved our goal, it may have cost
a deterioration in our relationship. But what causes this
type of problem and how can we change? In hindsight we
often think we could have handled a given situation better. However, hindsight would be better replaced by foresight. Assertiveness can be the key to change. We need
to develop an ability to say yes and no, or agree and
disagree in an appropriate manner.
Assertiveness
Assertiveness enables you to express yourself with confidence, without the inappropriate use of aggressive, passive
or manipulative behaviours (Bishop, 2000).
At the core of assertiveness is the recognition that both
you and the person you are communicating with have
basic rights (Bishop, 2000).
Aggression
When aggression is used as a form of communication, we
are ignoring the rights of the other person. This is the
key difference between aggressive and assertive behaviour. Aggressiveness might develop as a strategy because it
has worked in the past. Alternatively, it may be something
that we have witnessed in others when trying to assert
their authority. However, as noted by Paterson (2000), it
is a short-lived strategy.
their own rights. For example, this may be someone who

finds it difficult to say no to colleagues because they feel
that they ought to agree to the requests of others.
Passive aggression
This is a combination of aggressive and passive styles of
communication. Paterson (2000) notes that this strategy is
used when aggression is disguised. Classic examples
would be of someone grudgingly agreeing to a request or
sighing and muttering inaudibly before walking away.
The importance of verbal

and non-verbal skills
In order to conduct ourselves in an appropriately
assertive manner we must develop effective verbal and
non-verbal communication skills. Taken in isolation, the
content of what we say is not enough.The words need to
be conveyed with appropriate use of tone and volume. At
times, certain words or phrases may need to be stressed.
In face-to-face encounters, body language is a vital component of effective communication. Not only do we
need to sound confident, but our body language must
match the content of our delivery to achieve an air of
confidence. We must also listen and be sensitive to the
views or points made by the individual or individuals
concerned. Furthermore, we need to acknowledge the
constraints imposed on others when we are pushing to
reach a desired outcome.
Developing assertiveness skills

Having defined assertiveness and the difference between
assertiveness, aggressiveness, passiveness and passive-
ABSTRACT
Being assertive is not the same as being aggressive. Assertiveness is a tool
for expressing ourselves confidently, and a way of saying yes and no in
an appropriate way. This article explores issues concerned with
assertiveness in district nurse settings. It outlines helpful techniques to
develop assertiveness, such as the broken record, fogging, negative
assertion and negative inquiry.
Passiveness
KEY WORDS
In contrast to an aggressive communication style, when

an individual adopts a passive approach, they are ignoring
Assertiveness ! Communication ! District nursing
British Journal of Community Nursing Vol 10, No 6
281
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.197.016.213 on October 12, 2015. For personal use only. No other uses without permission. . All rights rese
It is often when we want to

say no that we find it most
difficult to be assertive. The
first technique to try is the use
of repetition, which is also
known as the broken record
technique. It is particularly
useful when dealing with
people who are unable to take
no for an answer. A new
district nurse may be
vulnerable to such
approaches. When using this
technique, you quietly repeat
a phrase back to the person.
aggressiveness,
we
want to highlight
some techniques that
can be used to
improve our assertiveness skills.
Firstly, we need to
examine why we are
reluctant
to
be
assertive. It might be
that we do not understand the concept fully
and associate it with
aggressiveness, selfishness or not appearing
to be nice. Timmins
and McCabe (2005)
report that a lack of
assertiveness may be
associated with a perception that to be
assertive demonstrates
uncaring behaviour. But, as we show in this article,
assertiveness is being able to say what you feel, while
respecting the other persons point of view. We suggest
that assertiveness is caring behaviour.
For example, you may find that your colleagues contact
you about a patient on a day off or when you are on holiday. Because you do not want to be thought of as uncaring, you do not voice your frustration or feelings of
anger. Instead, you agree to discuss the patient. However,
by saying nothing, are you inviting future intrusions into
your well-earned time off?
Saying no in an assertive way

the broken record technique
How can we say no in a way that allows us to remain
respectful of the other person?
It is often when we want to say no that we find it most
difficult to be assertive. The first technique to try is the
use of repetition which is also known as the broken
record technique (Smith, 1975). It is particularly useful
when dealing with people who are unable to take no for
an answer.A new district nurse may be vulnerable to such
approaches. When using this technique, you quietly

repeat a phrase back to the person, as shown in Box 1.
With each repetition, the goal is to stay very calm, keep
your tone of voice the same and avoid giving in to the
pressure. The broken record technique is an effective
assertiveness skill because you maintain your stance while
still showing respect for the other person.
Fogging
Another aspect of assertiveness is coping with criticism
from colleagues.
Smith (1975) suggests the use of fogging.This involves
listening closely to what the person is saying and
acknowledging that there may be some truth in it.
An example of fogging:
Lisa: You were really late for the meeting with

the new manager, thats really unacceptable.
Susan: You are right, Lisa, it was unacceptable
that I was late.
When you are using the fogging technique, you are
agreeing with the possibility that the person may be
right.
Negative assertion
The third technique is negative assertion (Smith, 1975).
This is when you accept that you may have made a mistake and agree with the criticism. Here is an example of
negative assertion.
Norma is a newly qualified district nurse and has found
the assessment of a new patient very difficult. She is being
challenged by a colleague and feels rather defensive about
her lack of confidence.
Kate: Your assessment and care plan is really

vague and useless, Norma.
Norma: (defensive) Well, I think it is alright.
OR
(negative assertion) You are probably right, Kate,
I have found this really challenging and dont
think I have done my best work.
Negative inquiry
Box 1. Example of the broken record technique
Sally: Fiona, will you take the student for me next week?
Fiona: No, I already have a student to take out with me.
Sally: But, another student will not really make much of
a difference
Fiona: I already have a student to take out with me.
Sally: But you are so good with students, it would really
help me out.
Fiona: I already have a student to take out with me.
Sally: Ok, then, I will ask Katy.
282
You may follow this with a fourth technique of negative

inquiry (Smith, 1975). This is when you follow up the
perceived criticism with a specific prompt to find out
more about the criticism.
For example:
What is it about the assessment that you think

is particularly vague, Kate?
If the criticism has been just, the individual will be able
to give examples of the problem which may be of help to
you. However, if the criticism is unjust, it is unlikely that
they will be able to generate any specific examples.
Box 2. Use of two assertiveness techniques

You have been to visit Mr Roberts who has lung cancer. You feel that his mood is very low and you are concerned
about him. You would like a GP to assess his mental state. However, you have always found todays duty doctor to be
dismissive of your opinions and you anticipate that today will be no different. You have also been taken off-guard or
had insufficient information or time to respond with confidence. The usual outcome of previous encounters is that you
either give in or do not pursue your requests.
Jenny: Dr Calder, I have been to see Mr. Roberts today and I am concerned about his mood. I wonder
if he may be depressed.
Dr Calder: He was fine last time I saw him have you become an expert in mental health now?
Jenny: You are right, I am not an expert in mental health (negative assertion) but I am very concerned
about Mr. Roberts mood (broken record).
Dr Calder: He was fine when I saw him last week.
Jenny: I saw him this morning and I think things might have changed. I am concerned that his mood
is very low (broken record). Also, he says that he is not sleeping well, has lost his appetite and has lost
interest in everything. He even said that he feels his life is rather pointless.
Dr Calder: You know, Jenny, that does sound different to when I saw him last week. Maybe I should
pay him a visit.
Jenny: Thanks, I would appreciate that.
Putting assertiveness skills

into practice
Making requests
Consider yourself in the following encounter between a

district nurse and the duty GP in Box 2. Could the use of
assertiveness skills help in this situation? This example
highlights the use of two techniques described above.
This type of situation can be particularly difficult if you
perceive that the individual carries more influence than
you. Not only is it essential to prepare for this meeting by
having all the relevant details about the patient, but also,
be ready to assert yourself when challenged.
Giving feedback
When giving feedback in an assertive manner, one useful
technique is the 3-step I message. Look again at the
example about being late for a meeting. If Susan is frequently late for meetings, Lisa might feel that she needs
to discuss the issue. However, the example illustrates
a rather aggressive approach when Lisa says Susan,
you are late.
The three step I message is a way of giving Susan feedback in a more useful and assertive way.
Lisa might rephrase the feedback as follows:
Susan, I feel angry when you are late for the

meetings with the manager because it means we
cannot use her limited time to discuss all the
staffing issues.
Here, your own feelings are expressed about the issue
and its effect in a particular situation. This is very different to the aggressive you make me so angry when you
are late.
Conclusion
Consider the types of encounters when you feel least
assertive. For example, you may feel that the person has
more influence than yourself.As a result you consider that
you have no right to disagree. This could be a situation
similar to that of Jenny and Dr Calder in Box 2. In this
type of scenario, it will help to plan ahead by working
through possible responses beforehand.
The rehearsal of assertiveness skills will also help in
spontaneous encounters when there is no time for planning.Whether the situation is pre-planned or spontaneous,
you can always learn to assert yourself.
BJCN
Bishop S (2000) Develop Your Assertiveness.. 2nd edn. Kogan Page, London
Deering C (1996) Learning to say no. Am J Nurs 96(4): 624
Paterson R (2000) The Assertiveness Workbook: How to express your ideas and
stand up for yourself at work and in relationships. New Harbinger, Oakland
Smith M (1975) When I Say No, I Feel Guilty. Bantam, New York
Timmins F, McCabe C (2005) How Assertive are nurses in the workplace?
A preliminary pilot study. J Nurs Manage 13(1): 617
KEY POINTS
!Assertiveness is a way of communicating with

another person while respecting both your and their
point of view, without having to resort to aggressive
or passive behaviour.
!Thinking about situations when you feel least
assertive is the first step to becoming more assertive.
Practising techniques such as fogging, negative
assertion and negative inquiry will help to develop
your skills.
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PROFESSIONAL DEVELOPMENT

Assertiveness: making yourself

nteractions with colleagues occur in many different

their own rights. For example, this may be someone who

The importance of verbal

Developing assertiveness skills

In contrast to an aggressive communication style, when

Assertiveness ! Communication ! District nursing

British Journal of Community Nursing Vol 10, No 6

It is often when we want to

Saying no in an assertive way

approaches. When using this technique, you quietly

Lisa: You were really late for the meeting with

Kate: Your assessment and care plan is really

You may follow this with a fourth technique of negative

What is it about the assessment that you think

British Journal of Community Nursing Vol 10, No 6

Box 2. Use of two assertiveness techniques

Putting assertiveness skills

Consider yourself in the following encounter between a

Susan, I feel angry when you are late for the

British Journal of Community Nursing Vol 10, No 6

!Assertiveness is a way of communicating with

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