Nurse Education in Practice (2009) 9, 322–330
Nurse Education in Practice www.elsevier.com/nepr
Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey Anna Deltsidou
*
School of Nursing Studies, Technological Educational Institution, 3rd Km Old National Road of Lamia Athens, Lamia, Greece Accepted 13 August 2008
KEYWORDS
Summary
Assertiveness; Bullying; Nursing students
Background: A number of studies of nursing and midwifery have found stress and bullying to be frequent problems. Those suffering from bullying and stress need to have high levels of assertiveness to resist and to cope successfully. Hence, it was considered vital to assess the assertiveness level of nursing students throughout their training curriculum. Methods: The study population was composed of nursing students in different semesters at one school in Central Greece (n = 298) who agreed to complete a questionnaire on assertiveness level assessment, which had been translated into Greek and adapted to this population. All students present in class completed the questionnaire, representing 80% of the total population of active students. Mean assertiveness scores between semesters were compared by ANOVA and comparisons between the responses of the first semester students and responses of advanced semester students were done by Pearson’s chi square. Results: The main finding of this study was that the assertiveness levels displayed by students increase slightly in advanced semesters by comparison to those displayed by first-semester students. Conclusions: Assertive behavior should be encouraged through learning methods. Nurses should preferably obtain this training throughout their studies. Instructors have an essential role in the improvement and achievement of assertiveness training curriculums for undergraduate nursing students. c 2008 Elsevier Ltd. All rights reserved.
Introduction
* Tel.: +30 2231060210. E-mail address:
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Communicating assertively implies the use of frank, straightforward communication that maintains and protects one’s rights in a constructive way. People
1471-5953/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2008.08.002
Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey who are assertive express their point of view while at the same time respecting the rights of others (Sudha, 2005). These views are expressed without ¨ zkan and Sevig ˘, 2007). Verbally anxiety and fear (O assertive communicators speak clearly, calmly, and frankly to those whom they are addressing (Mikanowicz, 2007), while setting goals and taking responsibility for their actions (Boggs, 2003). Nonverbally, they retain direct eye contact, and stand or sit in an upright position that is indicative of control and self-belief (Mikanowicz, 2007). Assertiveness differs from aggressiveness, which involves inappropriate expression of thoughts, emotions and beliefs in a way that violates the rights of others (Lawton and Stewart, 2005). It also differs from non-assertiveness, in that a non-assertive person functions passively and indirectly, which may lead to victimization ( Sudha, 2005). Assertiveness is thought to be a healthy form of behavior and helps people in personal empowerment. It is an invaluable component for successful professional practice ( Kilkus, 1993), with which many conflicts in a nursing situation can be successfully ruled out (Park and Yang, 2006).
Background Nurses interact with patients, colleagues and other health care professionals on a daily basis, and this interaction is improved when nurses have good communication skills. Several studies have suggested that nurses lack assertiveness skills, and that this deficiency in assertiveness results in diminished communication efficacy, thus compromising patient care (Poroch and McIntosh, 1995). By contrast, a positive association is considered to exist between assertiveness and definition of roles, occupation and job satisfaction (Lounsbury et al., 2003). As nurses and midwives move away from traditional roles, we recognize that there is an increasing need for them to behave assertively. Plenty of studies support the use of assertiveness skills in clinical settings. Even though forms of assertive behavior have been investigated in many situations, there is still insufficient empirical evidence with regard to the frequency and the use of assertiveness skills by nurses and midwives in clinical settings (Timmins and McCabe, 2005). Qualified nurses have been found to behave with less assertiveness at their workplace than they do in life in general, thus highlighting the multidimensional nature of assertiveness. Factors which endorse assertiveness in the workplace have been described, such as expertise, self-confidence, com-
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petence and wearing a uniform, whereas factors restricting assertive behavior are considered to be attitudes, education and the hierarchical organization determining a clinical setting (Gerry, 1989). Shipton (2002) found that the emotions generated by stress in the clinical experience had been reported to lead to nervousness, depression, anxiety, fear, disappointment, irritation, hopelessness, solitude and inferiority (Shipton 2002). This disappointment and vulnerability can be particularly severe when bullying is involved, and the victims of bullying need high levels of assertiveness to allow them to resist the associated stress. Hence, in general nurses use conciliation and escape as methods of coping with bullying and conflicts ( Valentine, 1995). However, although assertiveness is considered to be a positive and a valuable behavioral component, there is some doubt as to the effectiveness of assertiveness preparation (Gerry, 1989). Stress has been identified as a major problem in nursing careers worldwide (Wynne et al., 1993) and bullying in nursing and midwifery professions has been recognized as a major concern as well (Begley, 2002). Assertiveness is a means which can be used to work against bullying, improve stressful situations and enhance empowerment (Fulton, 1997). Studies have indicated that the majority of nurses think and work less assertively in the workplace than outside it ( Fulton, 1997), suggesting that training and socialization of nurses reduce assertiveness. Thus, there is a great need for a structured tutorial support which will endorses personal control, empowerment, assertiveness and self-reliance (Gammon and MorganSamuel, 2005), so that students experience less insecurity and deal with workplace stressful environment more efficiently. Moreover, studies on subjugation in nursing tend to support the conviction that the lack of assertiveness results from the reality that nursing is a demoralized, mainly female profession (Torres, 1988), but Farrell (2001) suggests that feeling subjugated is not the privilege of female nurses only, as male nurses also feel subjugated. As it has been mentioned, the literature is full of examples of the subjugated nature of the nursing profession (Farrell, 2001), and this subjugation, cultivated from their student years, is imposed on nurses in both clinical settings and the classroom. University students who have low self-esteem without a doubt exhibit negative professional attitudes and behaviors when they graduate. In this perspective, it is compulsory for nursing, midwifery, and education faculty students, who will provide individuals, families and society in the field
324 of health and education in the future, to be individuals with high self-esteem and assertiveness in order to be able to establish communication more comfortably in society and to be able to use their professional knowledge and skills more effectively ˘lu et al., 2008). (Karago ¨zog This study was designed to assess assertiveness levels of Greek nursing students at the beginning of and during their training program and the overall aim of the article was that the findings of this study could attribute to the development of new curricula in which strategies would be incorporated for teaching assertiveness to nursing students.
Methods This was a descriptive, quantitative study using a survey design. The study was carried out at a school of nursing in Central Greece. A number of students involved in the study had just taken up their studies, while the others were in various semesters of their four-year program. The curriculum of nursing studies in Greece does not include a specific course about assertiveness, but these skills are incorporated in other introductory courses to nursing. It was thought that assertiveness might differ according to semester, as a result of opportunities for discussion arising in class and differences in staff/student relationships. Although we know that gender can be a factor in assertiveness, in this study the gender of the students was not recorded, in order to retain local anonymity. The total number of participants was 298 students from different semesters. More precisely, there were 65 first semester students (21.8%), 69 second semester students (23.2%), 77 fourth semester students (25.8%), 73 fifth semester students (24.5%) and 14 seventh semester students (4.7%). The vast majority of these students were 40 (1.3%).
Instruments Following a review of the relevant literature, we chose an assessment tool of assertive behavior in nurses, developed by Begley and Glacken (2004). The questionnaire incorporates three dimensions of assertiveness: positive assertion, negative assertion and self-denial. Furthermore, three other areas were deemed to be of importance: the ability to deal with criticism, confronting others and the
A. Deltsidou spontaneous expression of feelings. The instrument appeared to be suitable for the present study and it includes 28 questions in the Likert four-point format type, with the options ‘always’, ‘often’, ‘rarely’ and ‘never’. This questionnaire was translated into Greek and back translated by another bilingual expert in order to ensure the accuracy of translation, after which it was tested on a group of 20 third-year student nurses near the end of their training and no problems were recognized with face validity (Raftopoulos and Theodosopoulou, 2002). The questions were easy to understand and they took 8 min to complete. The test for internal consistency (Cronbach’s Alpha) rendered a score of 0.653, demonstrating a satisfactory reliability coefficient (LoBiondo–Wood and Haber, 2005), and the instrument was thus considered to be appropriate. For the collection of demographic data, a different questionnaire was developed, including participants’ age, semester, status of employment and nationality, as well as the educational level of their ¨ zkan and Sevig ˘, 2007). parents (O
Data collection Ethical approval was granted by the Institution’s Ethical Committee. The researcher had the opportunity to meet with students during their first week in the classroom. The students were given a brief written research proposal and asked to answer all questions. They were told that their responses would be kept confidential and that if they did not wish to participate they should feel free to submit a blank questionnaire. In addition, they were promised that as soon as their data had been entered into the computer along with a code number identifier, their questionnaires would be disposed of. All students present in class completed the questionnaire (n = 298).
Data analysis In this section of the questionnaire, respondents marked each statement as ‘‘always’’, ‘‘often’’, ‘‘rarely’’ or ‘‘never’’. Four marks were given for ‘‘always’’, three for ‘‘often’’ and so on, when the statements were phrased in such a way that ‘‘always’’ would indicate the greatest assertiveness. Statements which were phrased in such a way that marking ‘‘always’’ would indicate a lack of assertiveness were reverse-scored, so that the higher the total was, the higher that person’s level of assertiveness was estimated to be.
Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey The data was coded and analyzed using the software package ‘SPSS’, version 15.0. Mean assertiveness scores between students’ responses in different semesters were compared by ANOVA and comparisons between responses of first semester students and responses of advanced semester students were carried out based on Pearson’s chi square. Due to the fact that advanced semester participants were combined in one group, an independent T-test was also used for the purpose of comparing the mean assertiveness scores between the two main groups.
Results Two-hundred ninety-eight students were present in class on the day the study was carried out (80% of the total population), and all of them completed the questionnaire (100% response rate).
First semester students’ feelings of assertiveness The lowest mean score (i.e. the lowest level of assertiveness) was recorded for question 14: ‘I try to avoid conflicts at work’, which gained a mean score of 1.39 (SD 0.585), placing the students’ average response just below ‘always’, tending slightly towards ‘often’. Fifty-eight of the respondents (95.08%) ticked either ‘always’ or ‘often’ in relation to this statement (Table 1). The highest mean score (i.e. the highest level of assertiveness) was awarded to question 7: ‘‘I want to know what my rights are in the workplace’’, which gained a mean score of 3.78 (SD 0.522), placing the students’ average reply three-quarters of the way from ‘rarely’ towards ‘never’. Sixty of the respondents (95.24%) stated that they would want to know what their rights were in the workplace, while only 3 (4.76%) said that they would rarely want to know their rights in the workplace (Table 1).
Advanced semesters students’ feelings of assertiveness The lowest mean score (i.e., lowest level of assertiveness) was recorded for question 15: ‘‘I am very careful to avoid hurting other people’s feelings’’, which gained a mean score of 1.42 (SD 0.642). Two hundred thirteen of the respondents (93.42%) ticked either ‘always’ or ‘often’ in relation to this statement (Table 1). Again, the highest mean score (i.e. the highest level of assertiveness) was awarded to question 15: ‘‘I want to know what my
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rights are in the workplace’’ which gained a mean score of 3.86 (SD 0.444), similar to the results from first semester participants. The majority of participants (n = 225, 96.98%) stated that they would want to know what their rights were in the workplace, while 7 (3.02%) said that they would rarely want to know what their rights were (Table 1).
Comparison of mean ‘‘level of assertiveness’’ scores The mean ‘‘level of assertiveness’’ score achieved by first semester participants was 72.36 (SD 6.671), whereas with advanced semesters participants it was 74.71 (SD 6.850) (Table 2). The minimum recorded total score was 58 and the maximum 103. Both were reached by advanced semester students. These mean assertiveness scores were compared by using the Independent T-test, which demonstrated a significant difference (p value = 0.037), denoting an improvement in students’ overall perceived assertiveness throughout their studies (Table 2).
Comparison of the proportions of agreement with each statement The proportions of agreement or disagreement with each statement were compared between the two groups of participants, and statistically significant differences were observed in five areas (Table 1). All differences discerned indicated an increase in assertiveness in the advanced semester students. Thus, in response to statement 9 (‘‘I would feel uncomfortable paying a compliment to a junior colleague’’), 28 of the first semester students (45.16%) stated that they always or often felt uncomfortable, compared with 71 (30.74%) of the advanced semester students (v2 11.029, p < 0.012, d.f. 3) (Table 1). Similarly, in response to statement 23 (‘‘When someone pays me a compliment, I feel unsure of what to say’’) 126 students in advanced semesters answered (55.02%) ‘‘always’’ or ‘‘often’’, compared to 41 (44.49%) of the first semester students (v2 7.957, p < 0.047, d.f. 3) (Table 1).
Discussion It is recognized worldwide that assertiveness skills are important at all levels of health care delivery, and in all health care roles, from student nurse to qualified practitioner, from the field of direct patient care to that of health strategy development
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Table 1
Comparison of responses between first and advanced semester participants
1. At work I tend to keep my feelings to myself 2. I feel uncomfortable asking a colleague to do a favor for me 3. I find it difficult to compliment or praise friends and acquaintances 4. If a senior colleague made an unreasonable request, I would refuse 5. I enjoy starting conversations with acquaintances and strangers 6. I find criticism from friends and acquaintances hard to take 7. I want to know what my rights are in the workplace 8. If a friend makes an unreasonable request, I would find it difficult to refuse 9. I would feel uncomfortable paying a compliment to a junior colleague 10. If I were busy, I would ignore the demands of a senior colleague 11. When I know a friend’s opinion is wrong, I would disagree with him/her 12. At work I feel unsure what to say when I am praised 13. I tend to be over-apologetic to friends and acquaintances
15. I am very careful to avoid hurting other people’s feelings
Always
Often
Rarely
Never
N
First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced
19 60 14 58 8 16 25 79 18 64 15 50 58 208 7 19 13 18 26 65 34 147 16 39 11 22 40 128 43 149
34 117 33 97 15 49 21 92 25 101 23 73 8 17 22 79 15 53 18 118 22 73 27 97 17 67 18 81 12 64
6 39 12 64 20 95 8 52 15 55 14 78 3 6 18 96 15 90 13 35 3 9 12 59 19 95 3 15 5 13
3 12 4 10 18 73 7 6 5 13 7 32 0 1 14 37 19 70 5 12 4 4 6 31 11 42 0 2 1 2
62 228 63 229 61 233 61 229 63 233 59 233 63 232 61 231 62 231 62 230 63 233 61 226 58 226 61 226 61 228
Pearson v2
p Value
d.f.
2.202
0.532
3
3.217
0.359
3
3.433
0.330
3
11.542
0.009
3
0.632
0.889
3
2.714
0.438
3
3.011
0.390
3
3.744
0.290
3
11.029
0.012
3
9.794
0.020
3
4.910
0.178
3
3.403
0.334
3
4.380
0.223
3
1.980
0.577
3
2.232
0.526
3
A. Deltsidou
14. I try to avoid conflicts at work
Semester
Table 1 (continued)
17. I would ask for constructive criticism about my work 18. When I am with friends, I am frank and honest about my feelings 19. If a colleague upset a patient I would challenge him/her about it 20. If I disagreed with a decision made by a senior colleague, I would tell him/ her 21. At work I avoid asking questions for fear of sounding stupid 22. I feel uncomfortable asking friends to do favors for me 23. When someone pays me a compliment, I feel unsure of what to say 24. If I were impressed by the actions of a senior colleague I would tell him/her 25. I tend to be over-apologetic to my colleagues 26. I tend to be over-concerned about patients’ welfare 27. I would feel uncomfortable expressing annoyance at a senior colleague 28. I am a follower rather than a leader
Always
Often
Rarely
Never
N
First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced First Advanced
4 15 3 6 42 151 16 49 28 105 3 6 11 30 14 31 34 118 10 12 24 76 5 17 6 27
27 105 12 28 15 66 19 86 19 87 14 48 28 99 27 95 17 82 11 63 31 121 28 84 23 77
25 98 21 104 2 10 16 66 13 34 23 92 19 69 17 63 8 22 30 98 6 20 17 95 26 91
5 11 21 89 3 2 9 24 2 1 20 81 4 30 3 40 3 5 11 55 0 11 13 31 8 33
63 229 57 227 62 229 60 225 62 227 60 227 62 228 61 229 62 227 62 228 61 228 63 227 63 228
Pearson v2
p Value
d.f.
1.069
0.785
3
4.344
0.227
3
5.018
0.170
3
1.934
0.586
3
5.510
0.138
3
1.087
0.783
3
2.630
0.452
3
7.957
0.047
3
2.859
0.414
3
10.649
0.014
3
3.552
0.314
3
5.125
0.163
3
0.475
0.924
3
Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey
16. In a group I make the decisions
Semester
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328 Table 2
A. Deltsidou Comparison of mean level of assertiveness between first and advanced semesters’ participants
First semester Advanced semesters
Mean
SD
N
Median
Minimum
Maximum
Independent T-test p value
72.36 74.71
6.671 6.850
45 203
72 75
60 58
87 103
0.037
(Benton, 1999). As nurses and midwives move away from traditional roles, an increasing need for them to behave assertively has been recognized. Plenty of studies support the use of assertiveness skills in clinical settings. Even though assertive behavior has been investigated in many situations, empirical evidence is as yet insufficient with respect to the frequency and use of assertiveness skills by nurses and midwives in clinical settings (Timmins and McCabe, 2005). One of the major tasks of an assertive nurse is to act as an advocate for her patients and carry out essential management responsibilities, such as modifying supervision and designation, thus contributing to the creation of a health care milieu that covers the needs of both users and workers (Walczak and Absolon, 2001). As the literature review has documented, nurses are regularly confronted with emotional and potentially distressing situations due to the stress-laden nature of nursing as an occupation. This applies in particular to the nursing student ( Lindop, 1999). According to Lipley (2001), nurses are also confronted with bullying, which is considered to be a most important cause of stress in their work environment and it leads in numerous physiological responses such as sickness, anxiety, and insomnia, as well as a variety of behavioral and psychological reactions manifesting as depression, irritability, nightmares and being introverted. These are not good coping strategies, and no human being should have to undergo such terrible experiences, particularly in their daily working lives (Edwards and O’Connell, 2007). It has been found that assertiveness can be employed to manage perceived stress efficiently, in both the general nursing population and the student nursing population (Tomaka et al., 1999). Poroch and McIntosh (1995) refer to the potential advantages of having nurses acquire assertiveness skills, which they consider to be significant, but also to the potential consequences of a lack of these skills, in particular if there is a real risk of suffering on the part of the patient. The finding of this study that an increase in levels of perceived assertiveness skills is observed in nursing students throughout their studies is encouraging. This conclusion is in accordance with a study conducted by Begley and Glacken (2004), as well as with a previous cohort study, in which Gray and
Smith (1999) found that the students who participated in the study acquired effective communications skills by the end of their studies, with a related development in their assertiveness. Begley and Brady (2002) suggested that graduates holding an ‘Irish Diploma in Nursing’ had improved assertiveness skills. These were also apparent to others, who observed that these qualified students adopted a more assertive behavior than nursing students trained in a traditional course of studies. Howard (2001) has detected two other significant findings. The first is that students considered their improved assertiveness to be due to the development of a defensive coping strategy, which was not the result of a planned educational policy. The second finding he has noted is that improved assertiveness may have a negative effect on these students’ personal or social lives, as families may find it difficult to adapt to these changes in the students’ personality. This should be taken into consideration, and sufficient support should be provided to nursing students in order to help them deal with such effects (McCabe and Timmins, 2003). Even though it has been found in the present study that there is an improvement in the levels of nursing students’ perceived assertiveness, it is considered that a further increase would be desirable. As it has been recognized that assertive behavior can be learnt, some researchers suggest the introduction of specific courses aimed at enhancing the acquisition of assertiveness skills in nursing students. This may be achieved by a combination of educational methods, which have proved to be efficient, such as discussions in connection with lectures or role playing, allowing nursing students to be effectively prepared in assertive behavior. Given that role modeling is still a very powerful educational approach in nursing, preparation with regard to assertiveness should also be more comprehensive, taking account of students’ probable role model, the traditional registered nurse, who has been found not to have the best assertive skills imaginable (Poroch and McIntosh, 1995). According to Chant et al. (2002) there is a need for a closer collaboration between preceptor-ship/mentor and nurse teachers, in order to enhance a better
Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey assimilation of theory and practice and eliminate of the existing gap between theory and practice, as well as to ensure communication between these two fundamental components of nursing studies. In the present study, the instrument used for measuring assertiveness levels in nursing students was developed by Begley and Glacken (2004), and it is considered to be valid although further investigation at other nursing schools in our country is suggested. Such investigation should also include an assessment of assertiveness levels in nursing staff, due to the lack of literature on this issue.
Limitations of this study This study involved only one school of nursing and did not carry out any sort of intervention (i.e. teaching specific assertive skills to the students). The results cannot, therefore, be generalized or deemed to apply to all other nursing schools. It must also be accepted that the assessment scale used, as is true of all similar self-report scales, may be liable elicit socially desirable responses.
Conclusions According to this study, nursing students’ perceived assertiveness grew progressively throughout their training. There is worldwide recognition of the fact that to act as effective, secure practitioners in a multi-professional team, registered nurses must be assertive. Given the probable stress that nursing students potentially experience throughout their training, their need to acquire assertiveness skills is equal to that of registered nurses. Despite this equivalent need, there is an obvious lack of literature concentrating on the mechanisms necessary in order to ensure that nursing students will indeed become assertive nurses. Assertive behavior may be encouraged through learning methods. It is preferable that nurses acquire these assertiveness skills throughout their studies, and hence nursing instructors have an essential role to play in the improvement and accomplishment of an assertiveness training curriculum for undergraduate nursing students. Training in assertiveness should be directed to the entire unit of patient/client interface and organizational level, and should include students and qualified staff. The best possible composition and method of delivery of such training needs is something that needs to be further investigated, but it should most certainly incorporate close cooperation amongst teachers and practitioners.
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Once agreed upon and put into practice, observed assessment of such training should also be compulsory, as it will lead to evidence-based comprehension of this essential learning issue.
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