Assertiveness, Having an "edge". Advice needed

morte, LPN, LVN · Mar 14, 2014

ask the person who said it, to give examples.

Ruby Vee, BSN · Mar 14, 2014

ICU nurses have to have strong personalities to advocate for their patients. In private hospitals, you have to be able to identify when you need a physician to eyeball your patient, list your reasons why and then call that physician at 3 AM and INSIST that he come see his patient. Even if he swears at you. That's difficult for a lot of nurses. A lot of nurses will back down, to the detriment of their patients.

In teaching hospitals, you have to be knowledgable enough to know when the intern is screwing up and confident enough not to let him do so. There are times why being shy is a handicap if you cannot overcome it enough to stand up for your patient and for what you know is right. One of the first lessons an intern is taught (in a good program, anyway) is that when the experienced ICU nurse asks you "Are you sure you really want to do that, DOCTOR?" you really don't want to do whatever "that" is. Not only do you as an ICU nurse need to know that "that" is a bad idea, you have to be able to stop the intern from doing it with a look and then explain to him afterward (in private) exactly WHY it was a bad idea.

If your patient's family is agitating him rather than calming him, you have to be able to stand up to the family and insist that they leave. Or at the very least stop doing whatever it is that is agitating him.

I hope this helps.

JeanOfAllTraits · Mar 14, 2014

^ exactly what I was going to say.

We're the eyes, ears, hands and the "somethings not right" feeling that the team relies on. It takes a strong personality because of the fact that it's a high stakes area. We can't be afraid to ask for clarification or why something isn't a good option for a patient or to just say that we don't know and we need help.

I understand how that would make you feel bummed, but don't overthink it. Assertiveness is something that is learnable, it's comes with experience and trusting your gut. If you ask good questions then you're off to a good start already. I'd ask the educator who said it how he or she thinks you could grow in that area. How I'm interpreting the comment is that he or she sees potential in you and you could do it. It'll just take some experience and learning so you can become confident and know when to step up.

I take it ICU is something you'd like to do?

Nurse_Jessie · Mar 18, 2014

I got the same feedback during my residency, and for me having confidence in my own assessment skins and knowledge of what was needed to helped me gain assertiveness. When you talk to a physician can you give a quick summary of the patient, the current problem, and what you think would help (SBAR)? In my experience, physicians respond better when you sound confident, which will help you gain confidence. When you wake up a physician at 3 AM, do you start getting nervous as they chew you out, or do you stay calm and explain why you called? Do you already know what the expected order would be, the expected outcome, and what would necessitate a second call? Do you have your most recent lab values and vitals at your fingertips when they call so you can read them off with confidence if they ask?

I'm still known as being sweet and more reserved than many of my coworkers, but I don't let myself be intimidated by physicians or other nurses. I have enough confidence in my assessment skills, and in my knowledge of what likely needs to be done, or what could be causing the issue to advocate for my patients when necessary. There is some element of "fake it until you make it." Run your ideas by a more experience co-worker and get their feedback so that you sound like you really know what you are talking about when you call for an order. Know how to set boundaries with patients and family. Speak with confidence and never stop increasing your knowledge, the more you know, the more confident you can be.

beckster_01, BSN, RN · Mar 24, 2014

^ Exactly. Being assertive is not synonymous with being mean. It is having confidence in knowing what is right for the patient. When I have a family agitating my patient I don't just tell them to leave them alone. I explain what their loved one is experiencing and why the interaction is agitating. If the family understands what the patient going through they usually leave them alone, but if they don't then I have the confidence to tell them "leave grandma alone, I mean it. I'm just trying to do what is best for her so she can heal." I've never had an issue. As far as doctors go, I am a 4 year old nurse. I have been practicing for as long as they attended school, and they certainly know more about complex disease process than I do. But they don't know more about nursing than I do. So when it comes to nursing issues and gut feelings I will stand my ground and get back up if needed. But I won't tell a doc how to treat the patient. They went to med school for a reason. I like to keep an open working relationship with the doctors, but I definitely utilize my nursing resources first if I have a question about a doctors judgement. I am also never afraid to talk to an upper level if I have a question.

mrsmsh42 · Mar 27, 2014

ICU nurses are frequently a tough-skinned crowd. ER nurses, too. You need a thick skin because you're surrounded by death and dying every single day. Med-surg just isn't like it. And when you as an RN are feeling that your patient is circling the drain, you need someone to pay attention to it NOW.

I don't yell. A crisis actually makes me calmer. It makes me no less assertive.

I had two nurses stare blankly at me one day, because I calmly said to them, "Could one of you get the crash cart, please?" When they didn't move, I said a little louder, "NOW, please." ...They literally shook their heads like in a cartoon. It didn't register at first because I said it calmly and I used 'please." That's how I am.

I'm at a teaching hospital now, and working in a clinic. Residents do the first assessments on burns some days. I've been there six weeks in clinic, but I have a lot of experience before that. The residents will be talking to the patient, and the MDs still look at me when they say, "This looks like a third degree burn with some cellulitis..." They're looking for a slight nod of my head to agree with them. And when the residents don't know which wound care is appropriate, they'll say something like, "And I'll let (me) do the wound care for you." And I dress it, and teach the patient (and resident)...who usually observes, and needs only to see it once. Then the next visit, they take over.

That's what you'll be able to do with time. In the ICU, it means during a code, you might toss out a suggestion for lidocaine....or it means that for a crazy patient, you say, "Doctor, would you like to start precedex now?" or "Have you thought about dopamine?" (when you have the bag already in your hand, and spiked...) ...instead of "Doctor, what do I do?'

It takes time. The next time you're at a code, get into the middle of it. Don't watch on the sides. At the codes at my last ICU, anyone who said, "I haven't done compressions in awhile" got to jump on the chest. Don't ask if you can drop drugs...know your ACLS, and get the next bristojet ready to drop and nudge your way over to the iv access.

You'll get there.

mimi90 · May 2, 2014

Great advice, as always.