Assertive Communication

There are many issues raised in this incident like empowerment, assertiveness, patient privacy, accountability, trust, decision making and disability discrimination, however the author will be focusing on assertive communication, patient empowerment, disability discrimination and accountability. The author feels that these are some of the most important legal, ethical and therapeutic areas in nursing, particularly patient empowerment and accountability.

Assertive Communication

Communication can be a continuum of behaviour, with aggression at one end and passivity at the opposite end. Assertive communication is a balance in the middle, this means being able to communicate in a direct and honest way which meets the needs of others and also the needs of self, (Wondrak, 1998).

Wondrak (1998) describes the passive person as ‘the person who consistently subordinates their own rights to their perception of the rights of others’. This passive type of behaviour may bring feelings or actions of helplessness, submission and indecision, (Wondrak, 1998, p96).

However people move up and down the continuum with different situations that they face. A person who is passive in one situation may be aggressive with the next situation. Wondrak (1998) describes aggressive behaviour as behaviour that ‘frequently camouflages a basic lack of self-confidence, which leads to attempts to overpower others to prove superiority’, (Wondrak, 1998, p96).

Quite often a person who is passive or submissive by nature may find that they too often agree to things that they do not want to do or do not agree with, this is known as non-assertiveness. Non-assertive interactions may lead to angry internal feelings or a build up of stress and irritability. Eventually these feelings are let out in an aggressive manner.

Assertiveness is a skill that needs practice to develop; the essential skills of assertiveness are self-awareness, negotiation, compromise and calm insistence, (Wondrak, 1998).

Self-awareness is the continual process of noticing and exploring aspects of the self with the intention of developing personal and interpersonal understanding, (Burnard, 1985). Negotiation is a skill that recognises the value of personal needs and the needs of others. Compromise is necessary when it is difficult to reach an agreement; both parties need to be prepared to give up certain ground in order for both to be content with the result. Calm insistence is a technique in which a person states their position clearly and calmly then sticks to it, repeating their point as necessary, (Wondrak, 1998).

In this particular incident the student nurse used assertive communication with the staff nurse. On arrival at the scene the student was uncertain about how to deal with what she was witnessing. However the patient’s obvious distress and the staff nurses’ attitude raised feelings of anger. Initially the student nurse could be placed at the passive end of the continuum as she felt helpless and indecisive. However the feelings of anger that she experienced could have taken her to the opposite end and led her to respond with aggression. In this instance the student was neither passive nor aggressive but assertive which had the desired effect and ended the incident. However later that day when approached by the patient’s parents the student nurse showed signs of passive communication by apologising although she had no need to. She also behaved passively by not having the confidence and being afraid to report the staff nurse to her manager.


Traditionally the patient has always been perceived as the weaker party in the care equation, now moves are being made to change this.

The NHS National Plan, the Health and Social Care Act 2001 and the Government’s Health Service Policy Agenda have all built in the concept of patient empowerment, (Tingle and Cribb, 2002).

The Nursing and Midwifery Councils Code of Professional Conduct 2002, section 2.1, states that ‘you must recognise and respect the role of patients and clients as partners in their care and the contribution they can make to it. This involves identifying their preferences regarding care and respecting these within the limits of professional practice, existing legislation, resources and the goals of the therapeutic relationship’, (Nursing and Midwifery Council, 2002, p3).

A patient’s ability to chose for themselves and determine their own lifestyle is an important aspect of physical and psychological wellbeing. Empowerment aims to encourage personal growth by developing assertiveness and self-esteem. People who feel they have little or no control over their circumstances or events in their lives have higher rates of illness and mortality, (Kenworthy, Snowley and Gilling, 2002).

This emphasises the responsibility on nurses to promote and encourage patient independence by recognising and respecting their involvement in the planning and delivery of care. It is important that nurses also recognise that empowering care optimises patient independence and disempowering care leads to increased patient dependence, (Faulkner, 2001).

Some health professionals however may feel that empowering patients constitutes a threat to their professional role and many dislike relinquishing any amount of control in a care situation, but empowerment is essentially about the process of enabling the patients’ personal control, (Alexander, Fawcett and Runciman, 2002).

With any patient it is important to empower them to be part of their own care and to make decisions about what happens to them. With the patient in question being disabled it is important to help her feel in control of her life and the things happening to her, for example, although she cannot dress herself she can be given the choice of what she wants to wear. This would promote feelings of self-worth and control therefore empowering the patient. If these types of decisions are continually taken away from the patient they will feel they have no control and that they are unimportant and worthless.

In 1967 Seligman put forward his theory of Learned Helplessness which was based on animal experiments. His theory was that if placed in an unpleasant situation from which there is no escape we would soon become resigned and never try to escape the situation in the future. This is a learned state, in which we believe in our own powerlessness which then makes any attempts to learn futile, (Atherton, 2002).

In relation to the incident reflected upon the nurse in question completely disempowered her patient. Although the situation was not directly related to practical nursing care it was still affecting the patient’s emotional wellbeing. By not listening to the patient’s protests the nurse had implied to the patient that she was unimportant and inferior. This risks the effect of feelings of worthlessness and inequality. The situation was extremely undignified for the patient. Section 2.2 of the NMC Code of Professional Conduct states that ‘you are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs, (Nursing and Midwifery Council, 2002, p3).

This also leads us to the question of whether such an incident would have occurred if the patient had not been physically disabled and unable to stop the situation.

Disability Discrimination

Discrimination against others is a widespread problem, however in recent decades there have been laws and acts passed to help prevent discrimination. Discrimination can occur in several ways, for example, Direct Discrimination which is where one person treats another person less favourably on the grounds of sex, race, religion, etc. Also there is Indirect Discrimination which is where a condition is applied to a situation so that the proportion of people of one sex, race, religion, etc who can comply with it is considerably smaller than the proportion of another. There are also discrimination acts such as Victimisation and segregation, (Dimond, 1995).

The Disability Discriminations Act came into force in 1995. The Disability Discriminations Act part 3 is concerned with access to goods and services. The act makes it unlawful for a service provider to discriminate against a disabled person in the standard of service which it provides to the disabled person or in the manner in which it provides a service to a disabled person. Under the list of service providers mentioned in the Disability Discriminations Act are emergency services, hospitals and clinics.

The act says one of the ways discrimination occurs is ‘when a service provider treats the disabled person less favourably for a reason relating to the disabled person’s disability than it treats or would treat others and when the service provider cannot show that the treatment is justified’, (Disability Rights Commission, 1998).

Under the act adults and children have protection from discrimination if they are disabled. A disabled person is defined as someone who has a physical or mental impairment which affects their ability to carry out normal day-to-day activities, the effects must be substantial, adverse or long term.

This means that the way in which a disabled person is treated is compared with how the service provider would treat or does treat others. If a disabled person were to take a service provider to court they would not have to show that they were treated less favourably than others if other people would have been treated better. It is unlawful for a service provider to offer a lower standard of service to disabled people than they would offer to others or to serve a disabled person in a worse manner. A lower standard of service may include such things as harassment or being offhand or rude.

The act also says that service providers are legally responsible for their employee’s actions. If an employee discriminates against a disabled person during the course of their work the service provider is responsible, (Disability Rights Commission, 1998).

The Human Rights Act 1998 also covers discrimination. The Act was designed to give further effect to the rights and freedoms guaranteed under the European Convention on Human Rights.

In Schedule 1, Part 1, Article 3 ‘The Prohibition of Torture’ it states that ‘No one shall be subjected to torture or to inhuman or degrading treatment or punishment’. The way in which the nurse treated her patient was emotionally degrading.

Article 14 of the Human Rights Act is the ‘Prohibition of Discrimination’. It states that ‘The enjoyment of the rights and freedoms set forth in this convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status’, (Her Majesty’s Stationary Office,1998, p16, 19).

In the health care profession it is not just the avoidance of discrimination that is important but also the recognition of any prejudice that we may have. It is only by recognising this that we will come to honour a patient’s uniqueness. Once a prejudice free nurse/patient relationship is formed the patient will be free to communicate openly and this will help them to make informed choices about their care, (Young, 1994).


The Nursing and Midwifery Council’s (NMC) Code of Professional Conduct states in section 1.3 that ‘You are personally accountable for your practice. This means that you are answerable for you actions and omissions, regardless of advice or directions from another professional’. Section 4.5 also states that ‘When working as a member of a team, you remain accountable for you professional conduct, any care you provide and any omission on your part’, (Nursing and Midwifery Council, 2002, p3, 7).

Accountability is defined by responsibility therefore any one who is responsible for someone or something can be held accountable. If someone is accountable they must be prepared to give an explanation or justification to relevant others for their judgements, intensions, acts and omissions if called upon to do so. Accountability is an essential dimension of professionalism that must be accepted by all professionals.

There are three aspects to accountability, moral, ethical and legal. In many day-to-day events we have a moral right to expect an explanation from someone we feel has caused an injustice towards us just as that person has a moral duty to provide an explanation to us. The extent and degree of moral accountability we have towards others depends on the relationship we have with them, (Hunt, 2003).

Professional accountability is about answering to clients, professional colleagues and other relevant professionals. The demand to give an account of our judgements, acts and omissions arises from the nature of the professional relationship. In professional ethics accountability has a central place. Here the readiness to explain ourselves applies only to those acts and omissions which attach to our professional role. Professional accountability does not exclude moral accountability but simply builds upon it. Breaking a patient’s confidence is a different matter to breaking a friend’s confidence. Even though a patient may be a complete stranger we have an ethical obligation to them as our patient and breaking a patient’s confidence is professionally wrong, this is what is meant by professional ethics.

In some areas of our lives, like our employment, we may be held accountable by the law; there are many ways in which our responsibilities are reinforced by legal means. Some areas of legal regulation are delegated out to professional regulatory bodies such as the Nursing and Midwifery Council or the General Medical Council (for Doctors). This legal delegation gives these regulatory bodies the power to strike a professional person from its register so that it would then be illegal for that person to practice in their profession, (Hunt, 2003).

If a nurse is found to have behaved in such a manner as to constitute ‘misconduct’ then he or she can be held liable to disciplinary action from the NMC (formally the UKCC). Failing to care for patients properly can be classed as misconduct. If a nurse was reported to the NMC the allegations would be investigated by an NMC officer and the nurse may then be asked to justify their actions and they will be held accountable for them, (McHale and Tingle, 2001).

In the incident being discussed the nurse in question could have been held professionally accountable for her actions by the hospital and by the NMC. However as she was not reported by the student nurse, the patient or the patients family she was not held professionally accountable and appropriately disciplined. She was however held morally accountable by the patient’s parent when they questioned her about the incident. Hopefully for the good of all her future patients she will never repeat such an act.