How to Move From Defensive to 'I Have This!'

Nursing is a profession that requires collaboration with other healthcare personnel. While we may be thinking and processing the immediate needs of patients, it is the ability of the nurse to communicate patient data with others that sets us apart. We understand the patient's progress, how they might educate themselves further about their diagnosis, potential discharge needs, and what details must be documented for care to proceed.

Yet it is this communication with other healthcare professionals where unsettling aspects of nursing can appear. We are questioned about care, expected to produce patient data by rote (labs, vital signs, medications). At times, we may become flustered or defensive, describing how busy and stressful our workload has become. This is ineffective. "Busy" has become standard for nurses.

However, no one enters nursing to be scolded, disparaged, or yelled at in a roomful of colleagues, although it continues to happen. The behavior should stop, but until it does, a few examples could lend insight on moving away from a defensive posture ("It has been too busy," "We are working short today," "We just had a code") to an attitude of "I have this!" regarding nursing process.

Here is one example. Despite your best intentions, the patient load is overwhelming and you have not been able to assess everyone on your list. By mid-morning, a physician arrives for rounds and he asks about the patient in 44B, the one you have not seen! Should you offer an excuse regarding why you have not been in the room? We could imagine the response…

Physicians are not interested in explanations regarding nursing assignments/potential crises unless it involves the patient(s) they are scheduled to see. Hearing about nurses working short-staffed is distressing to them, amplifying concerns that patient complications may be missed while they are hospitalized.

A superior way to manage this scenario would be the following: Explain to the physician that you have not completed a full assessment on the patient but could offer feedback from rounds. The patient in 44B appeared comfortable, in no distress, and postoperative vomiting had eased. Additionally, morning labs were available on the clipboard.

This response demonstrates a nurse who grasps the needs of professionals who have rounds to complete and orders to provide. This also represents a nurse who avoids a defensive posture, instead focusing on details he/she can offer. This is a nurse who will complete the assessment at the earliest opportunity, knowing that potential issues can be communicated at that time.

Another example is the following: Despite efforts to be an effective patient advocate, you believe that your information is not being heard by a physician.

Patients may discuss symptoms, fears, concerns, and areas of anxiety with a nurse before relaying feelings to a physician. A patient may feel that they are doing "worse" without specific details to support the apprehension. They may have a feeling of impending doom, or worsening pain, fatigue, or shortness of breath. I have cared for a patient in the intensive care unit who met all of these criteria. Sally did as well.

Throughout a 12-hour shift, Sally watched a patient deteriorate, without changes in vital signs or auscultation, but she knew the patient was getting worse. Sally contacted the physician twice during the evening, but the MD grew frustrated with the lack of clinical data to support the concern. Sally got yelled at, and during her second call, the physician hung up.

What was she to do? Sally could have gone home for the evening and hoped that her concerns were invalid, but she did not.

Sally communicated details to the shift supervisor, but that did not solve the problem. Knowing that she could not leave the issue for the oncoming shift, Sally called a third time, stating exactly what she was feeling.

"I do not believe that I communicated well during our previous conversations. I need to try one more time before leaving my shift," she stated. Suddenly, Sally had his ear. By taking accountability for calling repeatedly without supportive clinical data, she had his full attention.

The patient was examined and placed on mechanical ventilation. He survived the ordeal, and Sally learned a valuable lesson.

Nurses operate on "gut instinct" many times while providing care. This instinct is gray, obscure, not reinforced by raw data or clinical parameters. Yet we need to communicate effectively, even when there are obstacles present. Placing that third call was a way of saying "I have this," knowing that the physician could be angry or the phone could be disconnected again. With the odds against her, Sally persisted. That is what might be required to get results.

But suppose a physician has chosen to chastise you in full view of peers?

A great mentor gave me a tip for this. It sounds ridiculous, but try dropping a pen in mid-rant. In the time it takes to bend over and retrieve the pen, the individual's anger has begun to dissipate. This works with anyone. Try it — the move will make a believer out of you! Even if the angry participant is still going on and on, the act of bending over provides a brief respite to catch your breath (and your composure!).

The goal of each of these scenarios is to attain the attitude of a nurse who owns his/her day as opposed to one who is stressed and out of control, making excuses about how "busy" the environment has become. We may never be less anxious, but we can function as if we are proceeding as planned. Learning to transition to "I have this" provides maturity, confidence, calm.

You may even convince yourself (big smile).

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About Diane M. Goodman

Diane M. Goodman, BSN, MSN-C, APRN, is a semi-retired nurse practitioner who contributes to COVID-19 task force teams and dismantles vaccine disinformation, as well as publishing in various nursing venues. During decades at the bedside, Goodman worked in both private practice and critical care, carrying up to five nursing certifications simultaneously. Yet she is not all about nursing. She is equally passionate about her dogs and watching movies, enjoying both during time away from professional activities. Her tiny chihuahuas are contest winners, proving that both Momma and the dogs are busy, productive girls!

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