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4.3 The Becoming Assertive Action Ladder 8

10	Treading the fine line between pushing and yielding
9	Playing the power game
8	Staying in adult mode
7	Being communicatively skilful
6	‘Just do it!’ (JDI)
5	Creating the optimum conditions to assert self
4	Making a good argument
3	Authority to assert self
2	Ethically right to assert self
1	Feeing the need to assert self

Am I Poised Enough to Respond Differently?

      Reflection is always concerned with the development of poise – the ability to know and manage feelings. The practitioner has reflected to understand their feelings. This cue now prompts them to consider how they might manage their feelings in order to respond differently. They may need to confront any lurking negative thoughts, fears, or feelings that seem to get in the way. In Buddhism, this scrutiny is called Apramada, what I term ‘the guard at the gate of the senses’ ever watchful for any negative mental events that may influence responding differently (Sangharakshita 1998). It is an aspect of being mindful acting like a diligent censor, keeping the mind alert, and moving towards the vision which the practitioner desires.

      Practitioners often wear metaphoric suits of armour to protect themselves from the anxiety and emotions of caring and the suffering of others. Jade, one of the primary nurses at Burford Hospital said ‘I don’t come to work dressed in protective armour’ (Johns 1993). Dewey (1933, p. 30) observed:

      Unconscious fears also drive us into purely defensive attitudes that operate like coats of armour – not only to shut out new conceptions but even to prevent us from making new observations.

      Dewey believed that anxiety limited the practitioner’s ability to learn through experience. The professional is closed to protect self rather than open to possibility. ‘Armour’ is akin to professional detachment.

      Logstrup noted the radicality of the ethical demand (1997, p. 44):

      The demand asks me to take care of the other person’s life not only when it strengthens me but also when it is very unpleasant because it intrudes disturbingly into my own existence.

      Hence, why we might strive to meet the demand to care for the life of the other, it opens us to our own vulnerability and why we may wear suits of armour to survive.

      Coming to an understanding of one’s vulnerability begins a journey to unlearn defence mechanisms and learn to cope with it more effectively. The practitioner may need to review and develop their support mechanisms within the practice. To be able to say – ‘I’m struggling‘ without being judged incompetent. In my experience, there is little organisational sensitivity to the profound nature of caring work. The lack of recognition of emotional labour (James 1989; Bolton 2000) that somehow emotional work is natural women’s work, and therefore is unskilled doesn’t need to be taught, and is not valued, when emotional work is the greatest gift nurses can offer patients. Taylor (1992, p. 1042) noted a theme within the literature of how nurses have been dispossessed ‘of their essential humanness as human beings and as people, by emphasising their professional roles and responsibilities’. Taylor draws attention to the fact that nurses are human too and, as such, are vulnerable to the same issues that face their patients and families. The lack of recognition of humanness in nursing through a focus on roles and responsibilities has led practitioners to strive to be something they were clearly struggling to cope with. Consequently, they risk becoming alienated from themselves in their efforts to cope with and live with the contradictions in their lives. Jourard (1971) noted that such striving damages ‘the self’ and reinforces the need to cope in a vicious downward spiral of self‐destruction towards burnout and a state of anomie.

The reality of today’s NHS is that nurse shortages are reportedly reaching crisis point (Hall 2003); bed occupancy is constantly ‘red alert’. In such an environment, Wall et al. (1997) note that NHS staff suffer considerably more stress than any other workforce, with 28% recording levels above the symptom threshold. Wind the clock forward. BBC News reports that NHS Foundation Trusts need to resubmit their financial plans. Only essential posts should be filled. The news asks what impact on patient care. What impact on staff morale and stress. Pick up my local newspaper and staff morale at RCHT is low.¹⁰ Wind the clock forward to the 2019 general election and the conservatives are proposing 50 000 more nursing jobs. Tides turning. So why let it get so bad in the first place and putting lives at risk and in misery for both patients and staff?

Tools such as the feeling fluffy–feeling drained scale can help practitioners focus on stress factors and work at reducing them. At the end of your next shift, stop, reflect, and mark how stressed you feel along with the feeling fluffy–feeling drained visual analogue scale (Figure 4.2).¹¹

      Stewing in our own juices is not healthy. Imagine your body is like a water butt‐ slowly filling with stress. As it fills, we are more tired and more intolerant but contain it, that is until you feel you are drowning and then one of two things happens. Either you blow up inside and have a breakdown, or else you snap and ‘blow your top’. You rage at events or people (Wilkinson 1988; Parker 1990; Pike 1991).

      Pike (1991, p. 351) writes:

      Moral outrage ensues when the nurse’s attempts to operationalize a choice is thwarted by constraints. The outrage intensifies when these constraints not only block action, but also force a course of action that violates the nurse’s moral tenets.

      Then ask yourself:

       What factors contribute to your sense of feeling drained?

       What factors contribute to your sense of feeling light and fluffy?

       What do you need to do to home feeling more fluffy and less drained?

       Use this scale over a period of time to monitor stress patterns and any improvement in your ‘fluffiness’.¹²

FIGURE 4.2 The feeling fluffy–feeling drained scale.

      Many practitioners wear this T‐shirt. However, the water butt does have a drainage tap. Through reflection, the practitioner can learn to monitor her stress levels and open her tap. She can then drain and convert the stress into positive energy necessary to take appropriate action to resolve the sources of stress (Hall 1964) just as the gardener draws water from the water butt to water the flowers and nourish their growth. However, the tap might be blocked, requiring help to unblock it – again, the value of guidance. If stress accumulates then the risk of burnout looms large on the horizon. Cherniss (1980) describes burnout as a process in which

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