AACN News—November 2007—Opinions

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Vol. 24, No. 11, NOVEMBER 2007


President’s Note
Reclaiming Our Priorities

Just Say No?

Dave Hanson,
RN, MSN, CCRN, CNS

A ‘No’ uttered from deepest conviction is better and greater than a ‘Yes’ merely uttered to please, or what is worse, to avoid trouble. — Mohandas K. Gandhi

Eight medical errors are identified during a 12-hour shift, yet only one is reported. The errors involve two ICU patients cared for by the same nurse. How could this happen to an experienced nurse who also happens to be a nurse educator and patient safety researcher? For the complete story, read Beth Henneman’s first person account in October’s Critical Care Nurse.

Not reporting the other seven errors wasn’t a conscious choice, she explains. Like most other clinicians, she considered them routine problems in a busy ICU, not serious system problems. And like most hospitals, hers did not have straightforward reporting mechanisms for what were primarily communication errors—for example, inaccurate information presented on rounds, failure of the nurse during rounds to interrupt the process to correct misinformation, failure of the resident physician to attend to the nurse’s concern and the nurse’s failure to involve the attending physician—identified by The Joint Commission as the root cause of 6 in 10 sentinel events.

It always comes down to communication, doesn’t it? Communication is a fundamental priority we must reclaim in support of our core values of patients and families, safety and reliability. AACN’s Standards for Establishing and Sustaining Healthy Work Environments provide unambiguous support by requiring that our communication skills be as proficient as our clinical skills.

Many of the errors in Henneman’s compelling report involved saying No, an extraordinarily powerful word. When we’re on the receiving end, we may feel rebuffed, rejected, devalued, disapproved. When saying No we may fear retaliation or even losing our job, concern that a relationship will be damaged or perhaps embarrassment that we’re letting down a patient or their family. Maybe even guilt when we should have said No and didn’t.

What if No became a positive word? William Ury proposes just that. In his newest book, “The Power of a Positive No,” the renowned Harvard Negotiation Project mediator explains that No’s destructive power comes from using the word and simply stopping there. No is such a powerful word it has to be used carefully, intentionally and sparingly. Even so, the challenge we face can seem daunting—saying No while still getting to Yes. This will be an important concept if we are to be successful in reclaiming our priorities, because saying No while still getting to Yes can help refocus our priorities and profoundly transform our lives and those of others.
The tension between exercising our power and tending to our personal and professional relationships is at the very heart of our difficulty in saying No. Exercising power is central to saying No, but it has the potential to strain a relationship. In turn, tending to the relationship may seem to weaken our power. Ury suggests a way out of this trap.

Challenge the common assumption that it’s an either-or proposition. Either we use power to get what we want—at the expense of the relationship—or we use relationship at the cost of power. Ury calls for us to use both at the same time, engaging the other in a constructive and respectful confrontation. He refers to this way out, as a Positive No.

A Positive No starts with Yes and ends with Yes. The first Yes focuses on us and expresses our interests. Respect is the key to a Positive No. Respect for ourselves and what we seek and value. But also respect for the other person by identifying how the value is mutually shared and can reach beyond being told No.

Ury uses the familiar example of Southwest Airlines and how effective delivery of Positive No messages has contributed to the airline’s success. The first Yes expresses the company’s interests and is internally focused. It is Yes to success and profitability. Then comes the No—for example, no reserved seats or no heated meals—which has allowed Southwest to be remarkably efficient in turning around its planes from flight to flight. This makes possible the second Yes—to convenient schedules and more affordable fares, for example. This second Yes is externally focused and invites the passenger to a mutually acceptable agreement.

In our work as acute and critical care nurses this may be saying Yes to safe and reliable patient care. No to unacceptable behavior such as abusive language. Then Yes to true collaboration in order to improve a professional relationship.

I hope you’re captivated by Ury’s intriguing perspective and that you’ll look for my next column when we can explore how to use a Positive No to achieve our core values. Until then, perhaps you will get a copy of “The Power of a Positive No” and see how well its message fits for you.