1. Background
Effective communication between nurses and patients is a critical factor behind quality care delivery and a key component of sound nursing practice. It helps nurses identify patients’ needs and take appropriate actions for their fulfillment (1). The nurses’ competence in establishing effective communication with patients improves their self-confidence, demonstrates their professionalism, and earns others’ respect and gratitude (1). Moreover, effective communication enables nurses to accurately diagnose patients’ problems (2, 3), develop quality care plans, and establish professional relationships with other healthcare providers (2). Yet, a study on 1216 patients showed that 17% of them were dissatisfied with healthcare providers’ communication abilities (4).
Communication has three main types, namely passive, aggressive, and assertive. The most effective type of communication is the assertive type (5). Assertiveness is defined as the ability to equally value one’s and others’ beliefs and ideas. In other words, it is the ability to fulfill one’s needs, defend one’s rights, and express one’s feelings, beliefs, and thoughts while simultaneously considering and respecting others’ rights (6). Another definition for assertiveness is the abilities to say no, express desires and negative/positive feelings, and start, continue, and finish a conversation (7). It happens when a person is able to express his/her ideas in delicate situations (8). Assertiveness is an intrapersonal behavior developed in social interactions that helps individuals express their rights, feelings, and thoughts in acceptable ways (8).
Assertiveness has different outcomes. It helps people show positive social behaviors, have appropriate social interactions with others, and improve their problem-solving ability and self-awareness (9). Sound assertive behaviors enable people to establish closer relationships and express their needs and thoughts without feeling anxious or harming others (5). In healthcare settings, assertiveness strengthens interprofessional relationships, prevents workplace violence (10), reduces occupational stress, minimizes negligence, and improves nurses’ leadership ability, job satisfaction, professional autonomy, and professional efficacy (6). Besides, it can bring nurses professional dignity, enable them to solve their professional problems and prevent them from making inaccurate judgments (11). Assertiveness is also directly correlated with nurses’ caring skills (4). Because of its numerous outcomes, assertiveness is considered a valuable skill in nursing (6).
Despite the importance of assertiveness to sound nursing practice and quality care delivery, previous studies show that nurses have limited assertiveness. For instance, a study reported that 60% of nursing students suffered from some levels of unassertiveness, which had negatively affected their learning and efficacy in 40% of cases (12). Another study into students’ mental health reported limited assertiveness as one of the most important problems among university students (13).
To the best of our knowledge, limited studies have been conducted so far on nurses’ assertiveness in eastern and southeastern parts of Iran. Therefore, the present study was designed and undertaken to evaluate assertive behaviors among nurses in Qaen, an eastern city in Iran.
2. Methods
This cross-sectional descriptive-analytical study was conducted on all 160 nurses, auxiliary nurses, and anesthesia and operating room technicians who were working at Shoahday-e Qaen hospital, Qaen, Iran in summer 2017. The participants were recruited through the census method. Inclusion criteria were a hospital work experience of one year or more and an associate or higher degree in nursing, anesthesia, or operating room, or an auxiliary nursing diploma. Exclusion criterion was voluntary withdrawal from the study.
A demographic questionnaire and the Gambrill-Richey assertion inventory (14, 15) were employed for data collection. The items of the demographic questionnaire were age, gender, nursing degree, marital status, work experience, and organizational position. The Assertion Inventory contained 40 items. The participants were asked to answer the inventory in two rounds. In the first round, they rated their discomfort and anxiety for each item on a five-point scale from “None” to “Very much.” In the second round, they were asked to determine their probable behavioral response in actual situations. The total scores of the first and the second rounds represented the two dimensions of assertiveness, namely discomfort and response probability. The scores of these two dimensions were used to determine whether a respondent was indifferent, unassertive, anxious performer, or assertive (Table 1). An earlier study on 40 guidance-school female students reported that the 26-day test-retest correlation coefficients of the discomfort and the response probability dimensions of the assertion inventory were 0.82 and 0.67, respectively (16).
Table 1.Assertion Inventory Score Interpretation Based on the Scores of Its Two Dimensions
| Discomfort | Response Probability | |
|---|---|---|
| ≤ 104 | ≥ 105 | |
| ≥ 96 | Anxious performer | Unassertive |
| ≤ 95 | Assertive | Indifferent |
2.1. Ethical Considerations
This study obtained ethical approval from the ethics committee of Birjand University of Medical Sciences, Birjand, Iran (approval code: IR.BUMS.REC.1396.71). Participants were informed about the study aim and the confidential handling of their information.
Study data were analyzed using the SPSS for Windows program (v. 21.0). The Chi-square test was performed at a significance level of less than 0.05 to examine the relationship of assertiveness with demographic characteristics.
3. Results
From 160 participants, 141 completely filled out and returned their questionnaires. The mean of their age was 31.49 ± 7.3 with a range of 18 - 52, while the mean of their work experience was 24.8 ± 7.04 with a range of 1 - 29. Most participants were female (95 cases, 67.4%) and married (116 cases, 82.3%), and had bachelor’s degree in nursing (82 cases, 58.2%).
As Table 2 shows, 31.2% of the participants were unassertive and only 21.3% of them were assertive. Their assertiveness had no significant relationships with their gender, marital status, nursing degree, organizational position, and participation in social skills courses (P > 0.05; Table 3).
Table 2.Assertiveness Status Among Study Participants
| Assertiveness Status | No. (%) |
|---|---|
| Assertive | 30 (21.3) |
| Anxious performer | 46 (32.6) |
| Indifferent | 21 (14.9) |
| Unassertive | 44 (31.2) |
| Total | 141 (100) |
Table 3.Frequency Distributions of Participants’ Assertiveness Status Based on Their Demographic Characteristics
| Characteristics | Assertiveness Status; No. (%) | P Value | |||
|---|---|---|---|---|---|
| Assertive | Anxious Performer | Indifferent | Unassertive | ||
| Gender | 0.44 | ||||
| Male | 9 (19.6) | 17 (37.0) | 9 (19.6) | 11 (23.9) | |
| Female | 21 (22.1) | 29 (30.5) | 12 (12.6) | 33 (34.7) | |
| Marital status | 0.10 | ||||
| Married | 23 (19.8) | 41 (35.3) | 14 (12.1) | 38 (32.8) | |
| Single | 7 (28.0) | 5 (20.0) | 7 (28.0) | 6 (24.0) | |
| Nursing degree | 0.45 | ||||
| Auxiliary nurse | 6 (26.1) | 10 (43.5) | 4 (17.4) | 3 (13.0) | |
| Bachelor of Science | 17 (21.5) | 24 (30.4) | 9 (11.4) | 29 (36.7) | |
| Operating room associate diploma | 5 (27.8) | 4 (22.2) | 3 (16.7) | 6 (33.3) | |
| Anesthesia associate diploma | 0 (0) | 6 (40.0) | 4 (26.7) | 5 (33.3) | |
| Master of Sciences | 2 (33.3) | 2 (33.3) | 1 (16.7) | 1 (16.7) | |
| Organizational position | 0.75 | ||||
| Matron or supervisor | 1 (33.3) | 0 (0) | 1 (33.3) | 1 (33.3) | |
| Head nurse | 1 (11.1) | 3 (33.3) | 2 (22.2) | 3 (33.3) | |
| Staff nurse | 23 (19.8) | 39 (33.6) | 16 (13.8) | 38 (32.8) | |
| Ward clerk | 5 (38.5) | 4 (30.8) | 2 (15.4) | 2 (15.4) | |
| Participation in social skills courses | 0.95 | ||||
| Yes | 6 (20.7) | 10 (34.5) | 5 (17.2) | 8 (27.6) | |
| No | 24 (21.4) | 36 (32.1) | 16 (14.3) | 36 (32.1) | |
4. Discussion
This study assessed hospital nursing staff’s assertiveness and its relationship with their demographic characteristics. The findings showed that most participants had limited assertiveness (78.7%), i.e. were either anxious performer (32.6%), indifferent (14.9%) or unassertive (31.2%). Similarly, an earlier study reported that 66% of nurse entrepreneurs were unassertive, 47% were anxious performer, and only 24% of them had assertive behaviors (17).
Our findings also indicated that only 11.1% of head nurses and 19.8% of nurses had assertive behaviors. Similarly, two earlier studies reported that nurses had limited assertiveness (10, 18). These findings highlight the importance of developing strategies and programs for promoting nurses’ assertiveness. We also found that 21.3% of our participants were assertive and 31.2% were unassertive. These values in a previous study were 23.7% and 76.3%, respectively. That study also reported that greater assertiveness was associated with lower likelihood of suffering from violence (19). Another study on 274 bachelor’s nursing students in Turkey also reported that more than half of them had limited assertiveness in clinical settings (20). Moreover, a study on Iranian nursing and midwifery students found that 59.60% of them had moderate assertiveness, 22.20% had high assertiveness, and 18.21% had low assertiveness (6). In line with our findings, a study on internship nursing students found that the prevalence of high, moderate, and low assertiveness among them was 20%, 68%, and 12%, respectively (21). Another study also showed limited assertiveness among nursing students (22). Such low assertiveness among nurses and nursing students may be due to the unawareness of their legal rights, their low self-confidence, physicians’ dominance in healthcare settings, and managers’ reluctance to engage nurses in decision-making and policy-making and give them greater professional autonomy.
Our findings also indicated no significant difference between male and female participants respecting their assertiveness score, though female participants obtained slightly higher assertiveness scores than their male counterparts. This finding may be attributable to the greater number of females in the present study (67.4%) and their ability to communicate more easily with each other. In line with our findings, several earlier studies reported no significant relationship between gender and assertiveness (22-24). However, a study showed greater assertiveness among female nursing and midwifery students (6), while another study reported significantly greater assertiveness among male students (25). These discrepancies among studies can be due to the differences in their samples, designs, and data collection instruments. Moreover, gender socialization can be an explanation for the difference between men and women in terms of their assertiveness. In addition, men are engaged in social activities more than women are and hence, they are usually more assertive while women are more passive (22). However, the insignificant relationship between gender and assertiveness in the present study may be due to the obedience of both male and female nurses to physicians.
We also found that single participants were relatively more assertive than their married counterparts were, even though the difference was not statistically significant. The greater assertiveness of single individuals may be attributable to their lower familial commitment and lower concern over employment loss. Similarly, an earlier study found that single midwives were more assertive than their married counterparts were (26).
4.1. Conclusion
This study concludes that the hospital-nursing staff has limited assertiveness. Therefore, nursing managers need to implement educational programs in order to promote their assertiveness and self-confidence and thereby, improve care quality and patient satisfaction. Assertiveness can be a critical and life-saving skill in critical situations and can improve patients’ confidence in nurses’ abilities and competence. Given the potential effects of the immediate sociocultural context on assertiveness, the present study can be replicated in other contexts and on larger samples of hospital staff. Moreover, investigating the effects of interventions such as participatory management model, assertiveness training, and self-awareness and communication improvement strategies on assertiveness can be other areas for further research.
