Investigations into serious patient harm often find that someone, frequently a nurse, noticed the problem but did not speak up, or spoke up too softly to be heard. Hierarchy, fear of conflict, culture and inexperience all make it hard to challenge a senior colleague. Yet assertive communication is one of the most powerful safety tools nurses have.
This guide explains the difference between assertive, passive and aggressive communication, introduces practical tools such as CUS words and the two-challenge rule, gives scripts for common situations, and discusses how culture and hierarchy affect speaking up.
Imagine a surgeon is about to start an operation, but you notice the consent form lists the left knee and the marking is on the right. You feel your heart pounding. The surgeon is senior and impatient. You say quietly, “Um, I think maybe the side might be…” He waves you off. You stop. Now imagine instead: “I’m concerned. The consent says left knee; the mark is on the right. We need to stop and check.” Same nurse, same fear. A different sentence, and possibly a different outcome.
Passive, aggressive and assertive
| Style | What it looks like | Example |
|---|---|---|
| Passive | Hints, apologises, avoids conflict | “Sorry, it’s probably nothing, but…” |
| Aggressive | Blames, raises voice, disrespects | “You obviously didn’t read the chart!” |
| Assertive | Clear, respectful, specific, focused on the patient | “I’m concerned about Mr Bello’s blood pressure of 82/50. I need you to review him now.” |
Why nurses find it hard to speak up
- Hierarchy and fear of seniors’ reactions.
- Cultural norms of respect for elders and authority.
- Being new, a student or an internationally educated nurse in an unfamiliar culture.
- Past experiences of being dismissed or humiliated.
- Uncertainty: “What if I am wrong?”
- Fatigue and workload.
Tool 1: CUS words
From the TeamSTEPPS teamwork programme, CUS gives escalating, agreed phrases:
- “I’m Concerned…”
- “I’m Uncomfortable…”
- “This is a Safety issue.”
When a team has agreed that “This is a safety issue” means stop and listen, it cuts through hierarchy.
Tool 2: The two-challenge rule
If your concern is ignored, voice it at least twice. If it is still dismissed and the risk continues, you have the right and duty to escalate to a more senior person or take action to stop harm.
Tool 3: SBAR
Structure your message so it is clear and hard to dismiss: Situation, Background, Assessment, Recommendation. See SBAR examples.
Tool 4: “Stop the line”
Some organisations empower any team member to pause a procedure or process when they see a safety risk, using a standard phrase. Find out whether yours does.
Scripts for common situations
Deteriorating patient, prescriber not coming
“This is Ada, staff nurse on Ward 4. Mrs Okoro’s NEWS2 is 7, her respiratory rate is 28 and she is confused. I am worried she is septic. I need you to review her within 30 minutes. If you can’t, I will escalate to the registrar.”
Prescription you think is unsafe
“I’m not comfortable giving this dose. It is ten times the usual dose for her weight. Can we check it together with pharmacy before I give it?”
Colleague skipping hand hygiene
“Before you go in, there’s the gel. Infection rates matter on this ward. Thanks.”
Being asked to take an unsafe workload
“I can’t safely take two more patients with my current four. I can take one if someone helps with the discharge. Otherwise, I’ll need to raise this as a staffing concern.”
Body language and voice
- Stand or sit upright; make eye contact.
- Use a calm, firm voice; avoid trailing off.
- Use “I” statements and facts.
- Name the patient and the specific risk.
- Say what you need and by when.
When speaking up is not enough
If concerns are repeatedly ignored, use formal routes: incident reporting, your line manager, freedom to speak up guardians or equivalent, professional associations, and ultimately the regulator. Nursing codes require nurses to raise and escalate concerns about patient safety.
Internationally educated nurses
Nurses moving between cultures may find assertiveness expectations very different. What seems rude in one culture may be expected in another. Practising scripts, observing respected colleagues and asking mentors for feedback can help. Building assertiveness also links to emotional intelligence.
Frequently asked questions
What is assertiveness in nursing?
Communicating clearly, respectfully and confidently, especially to protect patient safety.
What does CUS stand for?
Concerned, Uncomfortable, Safety issue: escalating phrases for speaking up.
What is the two-challenge rule?
Voicing a concern at least twice; if still ignored, escalating or acting to prevent harm.
Is it disrespectful to challenge a senior doctor?
No. Respectful challenge for patient safety is a professional duty.
But what if I am wrong?
Then you will have checked, learned and kept the patient safe. Most senior clinicians would rather be questioned than make an avoidable error. Being wrong occasionally is far better than staying silent once when it matters.
Your next step: Write down the CUS phrases and one SBAR script on a card or your phone. Practise saying them out loud once before your next shift.
Related: SBAR examples · Emotional intelligence · Therapeutic communication
Sources: AHRQ TeamSTEPPS curriculum (CUS, two-challenge rule); WHO Patient Safety Curriculum Guide; nursing regulators’ codes on raising concerns.
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