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Providing mutual support also sometimes requires the use of advocacy and assertion. Advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decision maker. In advocating by or for the patient and asserting the need for corrective action, the patient, team, and family caregiver each have an opportunity to correct errors or the loss of situation awareness. Assertive statements plus the Two-Challenge Rule and CUS, discussed below, are tools that can help provide mutual support in an effective but respectful way.

Failure to use advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events. You should advocate for the patient even when your viewpoint is unpopular, is in opposition to another person's view, or questions authority. One common situation requiring advocacy and assertion involves the support of patients with limited English proficiency. An example illustrating appropriate advocacy for such a patient by insisting on the need for a medical interpreter follows:

TeamSTEPPS: Limited English Proficiency Safety: Success (6:09)

Fields that have been very hierarchical, such as healthcare, the military, and commercial aviation, have all experienced tragic failures because staff in subordinate positions failed to advocate or assert their concerns or because their leaders refused to listen. Changing this culture in healthcare is essential to protecting the safety of every patient. This change will also reduce stress, frustration, and burnout of staff whose safety concerns have been dismissed in the past.

When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, providing evidence or data to support your concerns. Assertive statements are nonthreatening, respectful ways to make sure the concern or critical information is addressed. They can easily be taught to patients and their families as a structured way to communicate their concerns to the rest of the care team.

Effective assertive statements are:

• Respectful and supportive of authority.
• Clear assertions of concerns and suggestions.
• Nonthreatening and ensure that critical information is addressed.

The process for assertive statements includes:

1. Open the discussion.
2. State the concern.
3. State the problem—real or perceived.
4. Offer a solution.
5. Obtain an agreement.

To make this process more concrete, consider a scenario in which one team member witnesses another team member treating a receptionist rudely in front of a patient. An assertive statement could be used to express her concerns about the staff member's behavior in the following way:

1. Open the discussion: "I'd like to share my thoughts on your discussion with the receptionist."
2. State the concern: "I am concerned that what you said and how you said it sounded rude."
3. State the problem, real or perceived: "And if I considered it rude, the patient may have as well. And that is not the type of behavior we want patients to see."
4. Offer a solution: "In the future, if you have feedback to give the receptionist, please so do privately in a constructive and respectful manner."
5. Obtain an agreement: "Can we agree that would be a better way to handle such situations?"

As another example, consider a scenario in which a medical floor nurse is assigned to a patient after a myocardial infarction.

The attending physician provides the final treatment, reviews the clinical situation, and determines that the patient is well enough to be discharged.

However, when the nurse checks the patient's vitals a final time, he observes that the blood pressure and heart rate are substantially elevated.

• If you were in this situation, what would you do to address the problem?
• How might you raise this issue with the physician?
• How would you construct an assertive statement to express the nurse's concerns?

In this scenario, an assertive statement may be appropriate even though the physician has done nothing wrong. Instead, the statement is being used to call attention to a potential change in the patient's condition that warrants reconsidering a decision made with potentially different information.