Have you ever been nailed by nasty remarks from a hostile family member? Ever been clobbered by comments from colleagues? How did you react? Were you able to gracefully defuse the situation? Or did you faint and fall down or rise up and attack? When communicating therapeutically with patients, most nurses are both 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. Although your résumé may focus on your experience with the “hard skills” of providing complex and highly technical nursing care, experts believe that “soft skills,” such as knowing how to manage the people part of your job, have a major impact on both your job satisfaction and your career advancement.¹ The good news is that, like other skills, your communication style can be improved with effort and practice.²

Your style makes a difference

Working in health requires outstanding communication skills.³ Communication is the transfer of understanding from one person to another.² Skillful communication is essential for clinical practice, for team building, and for maintaining a satisfying work climate. The ability to communicate effectively is one of the most important areas in which nurses need to be experts.^4,5 We communicate verbally by using words and tone of voice to transmit information, and nonverbally through facial expressions and gestures. Although nonverbal communication is always a vital part of our message, we are usually not aware of it. Thus, it’s important to make sure that our body language is consistent with our verbal message.^4,5

The style in which we communicate has a huge impact 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 communication style spectrum is the person with an aggressive style.⁵ People who use an aggressive style are often confrontational and choose words and use gestures that others perceive as sarcastic or even rude.⁴ 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.^4,6 He or she speaks in a well-modulated tone of voice and augments the verbal message by using direct eye contact and appropriate gestures and facial expressions. Assertive communication involves more than standing up for yourself. Assertiveness is the ability to communicate with others about who you are and what you want and the ability to make others feel they can respond in kind.⁶

Even when you’ve developed an assertive style, there are still pitfalls that can undermine your communication effectiveness. Giving unsolicited advice, becoming defensive, using a patronizing manner, giving false reassurances, and blaming others are all behaviors that can sabotage effective communication.⁷ Although it’s tempting to give advice when another person raises an issue or problem, advice giving tends to stop the communication process. It’s often more effective to allow the person with a problem 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.⁷ 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.⁷ Patronizing, or speaking down to another person, can stop the communication process in its tracks. Because as nurses we are motivated to relieve distress, we may have to resist the urge to give false reassurances. It helps to remember that it is unrealistic to expect that nurses can solve all problems or rescue everyone in need. A more therapeutic strategy is to support people as they work through uncomfortable situations by using active listening and solicited feedback. Blaming others is another communication stopper.

In nearly every situation, the responsibility for a communication breakdown is a joint responsibility.⁷ 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.”⁷

Gender differences also affect the communication process. Research has confirmed what most people have learned through experience: Men and women use different communication styles, and these differences can create misunderstandings.^6,8 There are important differences in the way men and women work alone and in groups and in how they communicate with each other in a work setting.⁸ Men tend to communicate to accomplish goals, while women often communicate to establish or to 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 a more passive or tentative approach.⁶

Communication experts suggest that men need to increase their skills in listening to women express their feelings and points of view. Women can improve their communication with men by being more direct, by explaining their reasons for their views, and by being more tolerant when disagreements become part of a conversation. Research also shows that both men and women have fewer successful strategies for controlling anger than any other emotional state, including anxiety and fear.⁹ There are also differences in what prompts an angry response. Men tend to become angry at loss of control, system inefficiencies, or lack of staff professionalism. Women experience both anger and hurt when they perceive other people as uncaring, unwilling to listen to them, or uninterested in forming a relationship.^6,9

Saying “no”

Responding to patient requests is an integral part of a nurse’s role. Additionally, you must respond to requests from many other people, including colleagues, other healthcare team members, visitors, and supervisors. Requests may range from a patient’s asking for your home telephone number or e-mail address to a coworker asking you to switch days off. Each request made of you usually is seen as reasonable from the point of view of the person making the request.^6,10 Assessing whether a request is unreasonable is your personal decision. A request may be considered unreasonable if it interferes with your ability to provide nursing care in a way that is consistent with your ethics and values or if it disrupts your personal life.¹⁰ Obviously, in some situations you must comply with a request, such as a legitimate request made by your supervisor. However, other situations arise in which people make demands on your time and skills that you should decline.

It’s often hard for nurses to turn down unreasonable requests because our strong need to be helpful can interfere with our right to say “no” clearly and directly.¹⁰ 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.¹⁰

Saying no to a request requires using an assertive, rather than an aggressive or passive, communication style.⁹ By being assertive, you protect yourself by turning down a request you choose not to handle and, at the same time, consider the feelings of the other person by refusing in a direct but polite manner. If you plan to refuse a request, tell the person so at the beginning of your conversation. Don’t give elaborate background information and bury your refusal toward the end of your reply. If it makes your refusal more palatable, give some concise reasons why you are not able to comply with the request. It’s also helpful to communicate that you understand the requestor’s dilemma even if you can’t solve it.¹⁰ If appropriate, suggest an alternative course of action. 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. Is there something else I can do to help you catch up?”

Dealing with distress

Healthcare restructuring has had a major effect on the expression of distress in the workplace. When too few nurses are spread too thin, caring for high-acuity patients and worried families, anger often is directed to nursing staff.⁹ Anger is a normal human emotion. However, when anger becomes destructive, it can make individuals feel vulnerable and even threatened.¹¹ Learning how to maintain your sensitivity to others so that you can respond in a caring and professional way without becoming distressed yourself requires good listening and assessment skills. The instinctive way to respond to anger is to respond aggressively. An aggressive response is likely to incite an angry person. When confronted with a request from an angry person, stop what you are doing, carefully listen to what the person is communicating, what he or she is feeling, what is being requested of you, and whether what the person is requesting is reasonable.¹⁰ (See “A Confrontation at the Nurses Station.”)

Besides the use of the appropriate words, the nonverbal manner in which you respond to a distressed person is also important. It is crucial for the person who is angry or upset to believe that he or she is being heard. To convey this impression, stop what you are doing, face the person, eliminate distractions, and give your full attention to the speaker.^8,12,13 If possible, move to a private area. It’s also important not to interrupt the person who is angry or upset.^5,13 Time is a precious commodity for most nurses, and the upset person may need your attention at a less-than-optimum time. However, taking the time up front to hear out a distressed person is a wise time investment because it increases the potential for problem solving. In dealing with coworkers who are angry, you can use several strategies to get communication back on track. Some helpful techniques include listening carefully to the source of the problem, increasing your aggressor’s awareness of the abusive behavior and its negative effects, and not losing your composure.^3,8

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 Paraphrasing what the angry person has said is a way of showing you are actively listening.¹³ If necessary, ask for more information so you can better understand the reason for the person’s angry reaction. Using “I” messages prevents you from assigning blame, which tends to aggravate a person who is already angry.³ 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 impact of the hostile communication. An assertive way of communicating this would be to say, “Dr. Brown, you may not realize that you are shouting at me. This makes me feel uncomfortable and prevents us from resolving this problem. I would be glad to talk to you when you lower your voice.”⁷ 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.⁷ It is important to set limits on the inappropriate expression of anger.⁸ 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.”¹⁴

As nurses, we encounter distressed people daily and need to find ways to relate to them that can help relieve their distress without upsetting us. We need to replace “the patient is always right” to “ the patient deserves respect.”¹² Nurses must be prepared to deal with the anger of patients, family members, and colleagues and even their own anger. Recognizing and minimizing communication barriers, using an assertive communication style, developing skill in refusing unreasonable requests, and knowing how to respond to an angry person can help you meet these workplace communication challenges.

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