By: Dr Jennifer Tylee

Conflict and Assertiveness

This module is equivalent to two regular lectures.

In module 3 we commenced looking at problems associated with verbal interaction and the hidden agendas that people have as a part of their interactions. We also looked at transactional analysis as a method of understanding what might be at the heart of some verbal responses. Without these understandings it is easy to see why there can be conflict in interpersonal interactions and therefore a failure to communicate and develop closeness to others. Obviously, if the meaning in the communication from a patient is misunderstood by the nurse, the nurse has little chance of interacting with the patient in a therapeutic manner. Similarly, in the work environment if there are problems with the verbal communication there will be discontent among the staff which will provide a less than effective environment for patient care. This module examines the nature of conflict in interpersonal situations in more detail. It also examines the appropriate use of assertiveness as a means of ensuring an effective work environment and therapeutic interactions with patients.

At the completion of this module you will be able to:

1. Define conflict.
2. Identify three negative and three positive aspects of conflict.
3. Define assertiveness.
4. Outline how assertive behaviours differ from passive and aggressive behaviours.
5. Outline the individual rights that are the basis of assertiveness.
6. Outline a plan or strategy for assertiveness.

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Conflict is a complex interpersonal process. Conflict basically refers to a disagreement. Interpersonal conflict then refers to disagreement between people who have some form of relationship. That relationship may be close, as may be the case in families, or it may be between patients and members of the health professions, or between co-workers and so forth.

Disagreements are of various types. For example: the goals to be pursued, the allocation of resources such as money and time, decisions to be made, behaviours that are considered appropriate or desirable. The health care settings such as hospitals are no different from any other organisation. There can be disagreements between the staff of the wards and the central administration about the allocation of resources. There can be disagreements between patients and staff about the amount of control the patients have over decision making about their own treatment. There can be disagreements between nursing staff about what is considered appropriate behaviour by nurses in the presence of medical specialists. So the lists of possible area for disagreement could go on.

It is important to remember that not all conflict is negative. If the disagreement is handled appropriately then it is an opportunity for growth in both the organisation and the individuals involved.

DeVito (1989, 336) outlines some negative aspects of interpersonal conflict. These are as follows:

1. Can lead to an increase of negative feeling towards the person involved which can hinder the development of the relationship. In the health care system this can effect the care of patients and the general communication in the work environment.
2. It frequently leads to a depletion of energy that could be spent in more productive endeavours. The internal conflicts between staff on a ward can deplete the energy available for effective patient care and can have the staff member’s minds preoccupied on their own problems and not therefore available to provide therapeutic interactions with patients.
3. It can lead to the isolation of oneself or the other person involved in the conflict. This is seen in hospital ward situations where there is a conflict between a patient and the nursing staff. The conflict can be over what is seen by the nursing staff as appropriate patient behaviour and the behaviour a patient is exhibiting. The nurses may avoid the patient who is labelled as difficult.

Some of the positive aspects of interpersonal conflict are as follows:

The most important positive aspect of conflict is that it can force people to consider the problem and to work out a potential solution. If productive strategies are used rather than negative ones then relationships may well emerge from the conflict stronger and more able to face difficult situations in a constructive manner.

Filley (1975 cited in DeVito 1989, 337) presents four major values in interpersonal conflicts. These are:

1. The conflict situation may reduce the probability of more serious conflicts arising.
2. The conflict can lead us into new ways of looking at situations and therefore it can enhance our creativity as it forces us to explore new ideas and ways of behaving.
3. When the conflict is in a group such as a work group it can increase group cohesion.
4. The conflict can enable groups to measure their strength and power or interpersonal abilities in the face of conflicts.

Exercise: Identifying your conflict strategies.

Think about your own way of dealing with conflict. How do you normally approach conflict and its resolution.

(Adapted from DeVito,1989, 339).

To assist you in the identification of how you normally deal with conflict. This in turn will assist you in understanding how others deal with conflict.

The following statements refer to the ways that you may communicate in interpersonal conflict. The situation is between yourself and another person with whom you have a relationship, for example a friend or colleague. Beside each of the statements write 'T' (for True) if the statement is a generally accurate description of your conflict behaviour. Write 'F' (for False) if the statement is a generally inaccurate description of your conflict behaviour.

Once you are finished, click the reveal button (below) to find out how to score the responses.

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Three Patterns in Communicating

Associated with the usual pattern of handling interpersonal conflict are three basic styles of communicating.

McKay, Davis and Fanning (1983, 115) present a summary of these three styles. You will notice a measure of correlation between the communication style and the way in which interpersonal conflict is managed. The three styles are passive, aggressive and assertive.

In this style you don’t directly express your feelings, thoughts and wishes. You may communicate them indirectly by frowning, crying, whispering something under your breath and so forth or you may withhold an expression of your feelings and wishes entirely.

In this style you may smile a lot and place the wishes and needs of others before your own and you probably do more than your fair share of the listening. You use a lot of disclaimers such as "I’m no expert…" or "I really shouldn’t be saying this …" . When someone asks you to do something you tend to do it (even if you don’t want to) rather than make excuses or say no.

The major attraction that people find in the passive style is that they do not have to take responsibility for their feelings and needs, there is someone else to make the decisions and to be protective. This is often seen in patients who ‘hand over’ responsibility for themselves to the health care professionals. This type of communication style by patients is often encouraged and indeed expected by the health professionals as it means that the patient will comply with their demands and requirements. The problem with this situation however, is that there is a loss of independence and it stifles the real needs, feelings and wishes of the person involved.

The passive style is often used in order to avoid conflict. However it often leads to conflict as the feelings and needs are suppressed and the person has to manipulate others in order to get what they want. Others resent the use of manipulation.

You are quite capable of saying how you feel, what you think and what you want but it is often at the expense of others. You tend to humiliate others by the use of sarcasm or humorous put downs. You are likely to go on the attack when you don’t get your way and you stir up guilt and resentment in others by pointing the finger of blame. Your sentences often begin with "You…" followed by an attack or a negative label. You frequently use the terms "always", "should" and "never". These are used to imply that you are right and superior.

The main reason people use the aggressive style is to win. The short term goals may be achieved with this style but in the long term people resist and resent the user who then ends up feeling frustrated and alone. The style does not allow for error or the softer feelings and uncertainties to be expressed.

When you communicate assertively you make statements about how you feel, think and what you want. You stand up for your rights but you also take into account the feelings and rights of others. You listen attentively and you reflect back to the speaker the content and feelings of the messages sent. You are open to negotiation and can make direct requests and refusals. You can give and receive complements and deal effectively with criticism without becoming hostile and defensive.

This style is a major part of effective interpersonal interactions and is essential for therapeutic communication with the patient. The style also ensures that the communication between health professionals is constructive.

Exercise: Interpersonal Styles

Angel &Petronko (1983, 9-10) provide the following examples to assist in the differentiation of the various interpersonal styles (passive, aggressive and assertive).

Aim:

• To assist in differentiating interpersonal styles.

Process:

1. Read the following situations and the possible responses.
2. Indicate whether the responses are:
           (P)assive,
           (A)ssertive, or
           a(G)gressive.
   

Situation 1

Mr Jones, a patient on the ward to which you are assigned is allergic to penicillin. There is a notice on the front of his chart to indicate the allergy. After receiving the results of his wound culture and sensitivity, the doctor decides that an antibiotic is needed and proceeds to order penicillin. As the nurse you might respond in a number of ways.

Situation 2

You and another nurse are working the 3pm –11pm shift and you are hurriedly trying to complete your charting before you leave. Three lights go on from the patient’s rooms, and you see the other nurse walking down the hall with her coat, ready to leave.

Exercise:

Review these three styles and how you usually respond to conflict. What is your usual style of interaction? As an entry in your personal/professional journal you can summarise how you usually respond.

What problems/difficulties do you think you might face when nursing?

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The non-assertive ways of communicating contain the hidden agendas and game playing that were covered in module 3. The assertive style is that of the adult of transactional analysis.

It has been recognised (Angel & Petronko 1983, 7) that nurses have been an oppressed and passive group. The main style of interaction that has been acceptable has been the passive style. Nurses have been the victims of domination and low self -esteem. However, nursing is developing into an autonomous, accountable profession and a part of this is the development of skills in assertiveness.

Nobody is assertive all of the time and learning assertiveness does not mean that it has to be used all of the time. However assertiveness training does teach how to express feelings, thoughts and wishes and to stand up for your legitimate rights without infringing on the rights and feelings of others. Learning to be assertive means that you are able to choose when is an appropriate time to use it.

Angel & Petronko (1983, 8) suggest that the goals of assertiveness are twofold:

1. To stand up for your rights without infringing on the rights of others.
2. To prevent the anxiety that often stops us from behaving assertively. The anxiety locks us into passive behaviour where our rights are denied or it precipitates aggressive behaviour where we violate the rights of others.

However as Alberti and Emmons (1978, 2) suggest, many people do not believe they have the right to be assertive. McKay et al (1983, 113) consider that anxiety and fear about being assertive stems from our childhood where, using transactional analysis terms, the parent tapes with their multitude of rules about ‘good’ and ‘bad’ behaviour hinder the ‘adult’ from functioning in an appropriate manner.

McKay et al (1983, 114-115) present the following list of rules that stem from the ‘parent’ requirements for ‘good’ behaviour. The table also presents a statement of your legitimate right as an adult. These rights are a reminder that you have a choice about what you accept in the present from the parent tapes. That you are no longer the accepting child but rather an adult with alternatives.

When you are reading the lists ask yourself the following questions.

Does the assumption remind you of rules that you learnt as a child?

Do you believe that the assumption applies to you as an adult?

Review the number of assumptions that reminded you of the rules you had as a child and those that you consider to apply as an adult. What does this information reveal about yourself? Can you see a link between this and your preferred style of interaction?

Understanding what your rights are and what behaving assertively or in the ‘adult’ mode means is quite a different thing from actually behaving in this way. There are, as we have already seen, the possibility of hidden agendas behind particular behaviour patterns. These hidden agendas are able to sustain a particular form of behaviour even when that behaviour might not be in the best interests of the person. For the purpose of personal and professional development it is important to consider the following questions.

(Adapted from McKay et al, 1983, 118-119)

1. What do I get out of behaving passively?
2. What would I have to give up if I behaved assertively (from the adult ego position) instead of passively?
3. What do I get out of behaving aggressively?
4. What would I have to give up if I behaved assertively (from the adult ego position) instead of aggressively?
5. What would I gain from behaving assertively (from the adult ego position)?

Assertive expression does not leave any doubt about what is being communicated. The meaning is expressed clearly. McKay et al (1983, 120) suggests that there are three parts to an assertive statement.

• Your perception of the situation.
• Your feelings about the situation.
• Your wants regarding the situation.

An example of assertive expression using the three components:

"When I think about changing a dressing I get very nervous. I’ve been feeling butterflies in my stomach since I told you I would change Mr Hanson’s dressing. Now I realise that I won’t be able to do it on my own. Would you assist me with the procedure."

Notice that the assertive statements present the facts without slipping into negative judgements.

A part of assertiveness is listening. The listening skills that are a part of tutorial sessions 4 and 5 need to be incorporated into the assertive/adult process. In summary, the listening skills that are needed in assertiveness are that you:

• Clear your own thoughts and feeling so that you are ready to listen.
• Put your full attention onto the other person so that you are able to identify their thoughts, feelings and wants. If you are uncertain about what the other person is expressing ask them for clarification. – that is, "Can you tell me more…?" or "I’m not really sure what you feel about…?" or "I’m uncertain what it is that you are asking, would you tell me…?"
• Reflect back to the other person what you heard of their thoughts, feelings and wants.

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Interpersonal conflict and failure to communicate are potential problems in all interpersonal relationships. Conflict however, does not have to have only negative consequences. It is an opportunity for developing a greater understanding of the other person and looking at the way we routinely see the world. There are three main styles in interpersonal interaction - passive, aggressive and assertive. The assertive approach corresponds to the interactions from the adult ego position that were covered in module 3. The assertive behaviour that is based on the basic rights of an individual were considered. The assertive expression contains the perception about the situation, the feelings about the situation and what is wanted in the situation.

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1. Exercise: Assertive skills practice

Using assertive skills feels awkward at first and hopefully you will be able to practice skills with sympathetic friends (maybe some of the other people in this subject will assist).

Aim:

• To have you think about assertive expression and apply it to your own social situations.

Process:

1. Think of a social situation in which you would like to be more assertive.
2. Write down specifically how you would like to behave in the situation – not how you would like to feel.
3. Write down the people involved in the social situation. Examples might be:

• I want to be able to say "no" when my friends want to go out and I have assignment work to do.
• I want to be able to tell my flatmate not to play the music loud when I am trying to study.
• I want to tell my parents how I feel when they criticise me on the phone.
4. For each of your assertive goals write the think, feel and want aspects of the messages.
5. Practice expressing yourself assertively in the situation. You can do this with a friend or you can use the ‘empty chair’ approach. In the ‘empty chair’ you imagine the person with whom you want to be assertive in a chair that is opposite you. In your minds eye see that person in the chair. Imagine what they look like, what they are wearing – so that you can clearly see them. Make your assertive statements to them as though they were in the chair listening. When you have finished move to the chair and imagine you were the other person – respond the way you think the other person would respond.

2. Read Chapter 1 The Importance of Assertiveness for Nurses in:

Angel, G. & Petronko, D.K. 1983, Developing the New Assertive Nurse: Essentials for Advancement, Springer, New York.

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Alberti, R.E. & Emmons, M.L. 1978, Your Perfect Right: A Guide to Assertive Behavior, Impact publishers, San Luis Obispo, California.

Angel, G. & Petronko, D.K. 1983, Developing the New Assertive Nurse: Essentials for Advancement, Springer, New York.

DeVito, J.A. 1989, The Interpersonal Communication Book, 5th edn, Harper and Row, New York.

McKay, M., Davis, M. & Fanning, P. 1983, Messages: The Communication Skills Book, New Harbinger, Oakland California.

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