How We Can Enhance Nurses’ Assertiveness: A Literature Review
Ayako Okuyama1* Cordula Wagner2,3 and Bart Bijnen4,5
1Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, Osaka, Japan
2EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
3NIVEL Netherlands Institute for Health Services Research, Utrecht, The Netherlands
4Institute for Education and Training, VU University Medical Centre, Amsterdam, The Netherlands
5Foreest Medical School, Medical Centre Alkmaar, Alkmaar, The Netherlands
*Corresponding author: Ayako Okuyama, Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, 1-7 Yamadaoka, Suita,
Osaka, 565-0871, Japan, Tel : +81-6-6879-2555; E-mail: [email protected]
Received date: June 10, 2014, Accepted date: August 25, 2014, Published date: August 28, 2014
Copyright: © 2014 Okuyama A et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objective : Assertiveness is important for effective team building in nursing. This article aims at evaluating the
results of the previous studies on nurses’ assertiveness in each decade in order to discuss the possible ways for
enhancing nurses’ assertiveness.
Methods : Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were
searched for English-language articles published from 1946 to December 2012. Article which described the
assertiveness of nurses and relevant factors related to assertiveness in a clinical setting or evaluated assertiveness
training.
Results : Twenty-five studies in 26 articles were identified. In the 1970s and 1980s, research demonstrated that
nurses perceived they are submissive helper and were less assertive. These studies indicated that educational
achievement was regarded as a key factor in nurses’ assertiveness. The study in 1990s demonstrated that at least
one population of nurses was assertive. The studies after 2000 suggested that nurses behave in a passive way,
conforming to the stereotype of a ‘nice’ nurse, and were less likely to disagree with others. A sense of responsibility
for patients, managers’ leadership, organisational culture, and relationship between colleagues were reported as
influencing factors of nurses’ assertiveness.
Conclusion : Recently, the number of nurses who are trained in higher educational institutions has increased.
Despite this, nurses still experience some difficulties assessing themselves. Nurses should understand their role at
the recent health care environment as a professional. Nurse managers should take a leadership to avoid nurses’
concerns of voicing their opinions in order to improve nurses’ assertiveness.
Keywords: Assertiveness; Interdisciplinary communication; Quality
of health care; Systematic review
Introduction
Nursing surveillance and monitoring activities are essential for the
patient care [1]. Nurses require the competence of clinical grasp (e.g.
what is happening to a patient) and clinical forethought (e.g.
prediction for patient condition) for providing patient appropriate
care [2]. Nurses are expected to show clinical leadership at the patient
bedside to provide direction and support to patients and the health
care team for integrating the care they provide to achieve positive
patient outcomes [3]. If necessary they assert their opinions to other
team members for changing the care plan for their patients [2]. On the
other hand, it has been shown that those who are aware of a problem
often either speak up and are ignored or do not speak up at all [4,5].
Assertiveness is a style of communication that enables nurses to
build effective team relationships. Collaboration with other team
members needs both a high level of assertiveness (meeting the own
need) and a high level of cooperation (meeting the other’s need) [6].
Assertiveness is described as expressing thoughts and feelings without
denying the rights of others [7]. Nurses’ ability to be assertive when
they are unsure or concerned about medical procedures, the treatment
of patients, or symptoms of patients is key in reducing risk and
preventing major medical errors [8]. Assertive people inform others of
their needs and feelings, and communicate their message effectively
without causing offence to others [9]. When nurses act assertively,
they are more likely to provide patients appropriate care, and in doing
so, improve the quality of patient care [2,9].
Traditionally, nurses tend to be female and their role involves
assisting a doctor. As they play a supporting role, they are often placed
lower in the medical hierarchy, and it makes nurses difficult to assert
their own opinions for the patient care. Recently nurses’ role in the
clinical setting is changing. Since the Institute of Medicine published
the report of ‘The Future of Nursing: leading change, advancing
health’ in 2011, nurses are expected to act as partners with other health
care professionals and to lead in the improvement and redesign of the
health care system [10]. In addition, nurses are crucial in preventing
medical errors, reducing rates of infection, and even facilitating
patients’ transition from hospital to home [10]. It means that nurses
Nursing and Care Okuyama et al., J Nurs Care 2014, 3:5
http://dx.doi.org/10.4172/2167-1168.1000194
Review Article Open Access
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
are expected to acquire assertiveness in order to work effectively with
other health care professionals.
Lyndon conducted a literature review of nurses’ assertiveness and
teamwork, and reported that two studies of assertiveness showed
conflicting results [11]: Gerry in 1989 found that nurses rated
themselves more assertive outside of work than at work and
demonstrated a trend toward conflict avoidance [12], while Kilkus in
1993 found that nurses had mean scores in the moderately assertive
[13]. She concluded that findings regarding nurses’ assertiveness were
mixed [11]. She evaluated the results of the previous studies on nurses’
assertiveness using only six articles, and did not take into account the
changes of nurses’ work environment. Therefore, this review aims at
evaluating the results of the previous studies on nurses’ assertiveness
each decade in order to discuss the possible ways for enhancing nurses’
assertiveness.
Methods
This review was conducted as a part of systematic review for health
care professionals’ voicing behaviour. In the process of the literature
review, we found two types of articles pertaining to clinicians’
communication behaviour: the first focussed on speaking-up
behaviour related to patient safety (i.e. when clinicians are aware of
risky or negligent actions of others within health care teams) and the
second investigated the assertiveness of nurses more generally, without
focusing on patient safety issues. This article summarises the literature
on the latter type of assertiveness in nurses and discusses a strategy to
enhance team communication. Our findings on speaking up
behaviours in situations related to patient safety are reported
elsewhere [14].
Search methods
Relevant articles published in English from 1946 until December
2012 were searched using PubMED, MEDLINE, the Cumulative Index
to Nursing and Allied Health Literature (CIHNAL), Web of Science,
and the Cochrane Library (date last searched 24 December 2012).
Combinations of terms were used to find articles related to
assertiveness (i.e. speak* up, speak* out, assertive*), inter-professional
relations (i.e. inter-professional relations, doctor-nurse relationships),
health personnel (i.e. health personnel, patient care team, nursing-
supervisory, attitude of health personnel, professional role,
professional practice), and patient safety (i.e. risk management, safety,
medical errors, malpractice, professional misconduct, quality of health
care, outcomes and process assessment, program evaluation, quality of
health care, outcome and process assessment, program evaluation,
quality assurance, consumer satisfaction, doctor’s practice patterns,
nurse’s practice patterns, practice management) . Medical Subject
Headings were used where available. The search was conducted with
the assistance of experts in the use of such databases.
Moreover, a manual search (that involved reading the title of each
paper in the journal’s archives) was conducted to find relevant papers
on organisational research and nursing management in the Journal of
Nursing Management and the Journal of Organizational Behavior. The
referenced articles listed in each of the selected publications were also
examined.
To obtain a wide variety of research evidence, this review prioritised
articles that appeared to be relevant to nurses’ assertiveness rather than
particular study types or articles that met particular methodological
standards [15]. Both quantitative and qualitative studies were included
in this review. Articles that were selected for use in the review either
described the assertiveness of nurses and relevant factors related to
assertiveness in a clinical setting. In addition, articles which evaluated
the assertive training using the comparative study design were also
selected, while articles that described training programmes without
any results or expert validation were excluded. Review article of
nurses’ assertiveness were also excluded, and here original articles
which mentioned in the review were used for the analysis. At first, we
searched for assertive behaviour associated with doctors, medical
residents, and nurses. However, we did not find any research articles
on the assertive behaviour of doctors and medical residents, using our
criteria. Therefore, this article deals with only the literature concerning
assertive behaviour in nurses.
Two independent reviewers (AO, and a research assistant) reviewed
the titles and abstracts of citations generated by the search to assess
their eligibility for further review based on the selection criteria. They
selected relevant articles for possible inclusion. Cohen’s kappa was
calculated to assess the degree of agreement between both reviewers.
The reviewers assessed all of the selected articles in relation to the
criteria and decided independently which articles to include in this
study. In the case of disagreement between the two reviewers, the
article was discussed with the other two authors (CW, BB).
Search outcome
The initial search identified 2,941 citations. Most of the excluded
2,649 articles were based solely on expert opinions and commentary,
or did not study assertiveness in health care teams. In total, 292 articles
meeting the inclusion criteria were selected for detailed review (Figure
1). Following a title and abstract review by the aforementioned two
reviewers, Cohen’s kappa was calculated as 0.64.
Twenty articles dealt with the assertiveness of nurses. In addition,
five other articles were retrieved from article reference lists, and one
article was found using a manual search. In total, 25 studies in 26
articles were identified for this study. Nine articles (35%) were
published after the year 2000. Fifteen studies (60%) came from the
U.S., and of the remaining ten, eight originated from Japan, Australia,
Canada, and Ireland (two from each of these countries).
Quality appraisal
The following criteria were used to assess primary study quality: (1)
the aims and objectives of the research are clearly stated, (2) the design
is clearly specified and appropriate for the aims and objectives of the
research, (3) the researchers provide a clear account of the process by
which their findings were reproduced, (4) the researchers include
enough data to support their interpretations and conclusions, and (5)
the method of analysis is appropriate and adequately executed [15]. In
addition, we evaluated the study on the training intervention using the
modified Best Medical Education Coding sheet (e.g., study design,
participants allocation, outcome level (Kirkpatrick level))[16]. The
results of the study appraisal are shown in each table.
Data abstraction
Two reviewers independently abstracted the data from the selected
articles (e.g. study aim, design, method, results, and country where the
study was conducted).
Synthesis
Nurses’ assertiveness may influence on the trend of the times (e.g.
nurses’ work environment), therefore, themes emerged for each
decade that research on assertiveness was conducted. As a result, the
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 2 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
evidence was summarised per decade. A meta-analysis could not be
conducted because of the heterogeneity of the data.
Figure 1: Article selection process.
Results and Discussion
Nurses’ assertiveness in the 1970s and 1980s
In this period, six articles that investigated nurses’ assertiveness met
our criteria and were thus selected (Table 1) [12,17-21]. According to
these researchers, nurses were less assertive, predominantly because
they were female, experienced traditional training framed within a
hierarchical structure, and perceived themselves as submissive helpers.
Studies in this era investigated mainly the relationship between
individual characteristics (e.g., age, level of education, job position)
and assertiveness. In this decade, the educational background of
nurses was regarded as a key factor in their assertiveness. Nurses were
mainly educated at a nursing school (e.g., diploma programme), while
doctors were educated at a higher level of academic success than did
nurses. Nurses who accepted their professional role, had confidence
based on their knowledge and nursing experience, showed more
assertiveness [12,18]. However, it should be noted that small sample
sizes and a lack of a robust experimental design limit the
generalizability of these findings. In addition, four out of six studies
were carried out in the U.S.. Assertiveness of nurses who have different
cultural background can work differently in other countries.
Author (s),
Year, Country
Aim of study Sample size and
description
Measurements and analysis Main results Study appraisal*
Gerry [12] To explore nurses’
assertiveness at work and in
general life situations.
99 nurses from three
hospitals.
Combination of scales from the
Assertiveness Inventory, Rathus
Assertiveness Schedule,
College Self Expression Scale,
Pearson correlations. Semi-
structured interview: content
analysis.
Nurses are found to be less
assertive at work than in general life
situations. Senior nurses are more
assertive than staff nurses. Factors
which promote assertive are
knowledge, confidence, and
experience. Inhibitive factors are
traditional training and a hierarchical
structure.
1. Yes
2. Yes
3. Yes
4. Yes
5. Weak
Farley [17] To compare interpersonal
communication
86 nurses from 47
hospitals.
Power Orientation Scale, Social
Style Profile, t-test.
Nurse administrators held more
positive orientations to three of the
six power orientations, and were
perceived to communicate more
assertively than staff nurses.
1. Yes
2. Yes
3. Yes
4. Weak
5. Yes
Kinney [18] To examine the relationship
of conception and
personality.
101 nurses in a
university.
Nursing Role Conception Scale,
Ego Development Sentence
Completion Test, Personal
Attributes Questionnaire, Adult
Assertiveness was significantly
related to professional role
conception.
1. Yes
2. Yes
3. Yes
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 3 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
Self-Expression Scale,
Spearman rank order correlation
analysis.
4. Weak
5. Weak
Athayde [19] To compare assertiveness
levels in two different cities.
116 nurses in San
Francisco and the
Huston.
8 original operating situations, a
nonparametric statistical test.
Nurses employed in San Francisco
were more assertive than those in
Houston. As a result of the small
study sample, a number of
demographic factors were not
consistently related to assertiveness
when subjects in the two cities were
compared. In both geographical
areas, a high level of assertiveness
was associated with collegiate
nursing education.
1. Yes
2. Weak
3. Yes
4. Yes
5. Yes/No
Gluck &
Charter [20]
To find nurses who need
continuing education for
interpersonal effectiveness.
A random sample of
125 nurses from 268
nurses at a VA
hospital.
16 Personality Factor
Questionnaire, ANOVA.
Nurses with 21 or more years’
experience were found to be
significantly less assertive than
nurses with one to five years of
experience.
1. Yes
2. Yes
3. Yes
4. Weak
5. Yes
Miller [21] To evaluate nurses’
assertiveness during nurse
practitioner training.
64 nurses. Rathus Assertive Scale,
Spielberger Sate-Trait Anxiety
Scale, Spence Helmreich
Attitude Toward Women Scale,
Bem Sex Role Inventory, t-test.
The nurse practitioner students
became more assertive during and
after the training.
1. Yes
2. Yes
3. Weak
4. Weak
5. Yes
Table 1: Characteristics of selected studies from the 1970s and 1980s
*Study appraisal: 1) the aims and objectives of the research are
clearly stated; 2) the researchers design is clearly specified and
appropriate for the aims and objectives of the research; 3) the
researchers provide a clear account of the process by which their
findings were reproduced; 4) the researchers display enough data to
support their interpretations and conclusions, and 5) the method of
analysis is appropriate and adequately executed.
Author, Year,
Country
Aim of study Sample size and
description
Measurements and
analysis
Main results Study appraisal*
Poroch &
McIntosh [9]
To investigate the barriers
of assertiveness.
200 nurses randomly
sampled from a hospital.
Assertiveness Behaviour
Inventory Tool, original
Barriers to Assertive Skills in
Nurses, Pearson’s
correlation, t-test, Chi-
squared statistic, ANOVA.
Nurses considered themselves to
have moderate to low assertiveness
skills. Junior nurses are more
assertive than senior nurses (t = 2.75,
p = 0.00). A significant negative
correlation was found between the
level of assertiveness and the
perception of barriers inhibiting
assertive behaviour (e.g. fear
punishment from colleagues and
uncertainty about the differences
between assertive and aggressive
behaviour).
1. Yes
2. Yes
3. Yes
4. Weak
5. Yes
Johnson [22] To examine the
relationship between
assertiveness and self-
esteem.
164 nurses from
members of the NSW
Operating Theatre
Association in Australia
and the Australian
Institute of Radiography.
Rathus Assertiveness
Schedule, the Health
Employees Assertiveness
Scale, Rosenberg Self-
Esteem Scale, the Self-
Esteem Components Scale,
and demographic
characteristics, Pearson
correlation.
There were positive correlations
between each of the assertiveness
scales and each of the self-esteem
scales (p < 0.05).
1. Yes
2. Yes
3. Yes
4. Yes
5. Weak
Kilkus [13] To determine
assertiveness levels.
500 nurses randomly
from the list of active
licensees registered with
Rathus Assertiveness
Schedule, demographic
characteristics, ANOVA.
Majority of nurses in this study are
assertive. Nurses older 60 years old
were less assertive. Nurses who have
1. Yes
2. Yes
3. Yes
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 4 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
the Minnesota State
Board of Nursing.
higher levels of education were more
assertive.
4. Yes
5. Yes
Kruse [23] To compare the
assertiveness levels of
staff nurses and nurse
leaders.
200 staff nurses and 200
nurse leaders.
Rathus Assertiveness
Schedule, demographic
characteristics, t-test.
Staff nurses with a mean age of 40
years, employed full time, higher
educational level, possessed more
assertive behaviours than nurse
leaders did (t = 2.51, p = 0.02).
1. Yes
2. Yes/No
3. Weak
4. Weak
5. Yes
Lavin [24] To examine the
relationship between
assertiveness, self-
esteem, and management
style.
77 female registered
nurses at medical
surgical units in 10 acute
hospitals.
Cooper Smith Self Esteem
Inventory, Tennessee Self
Concept Scale, Assertion
Inventory, Thomas Kilmann
Conflict Mode Instrument,
correlation coefficient
analysis.
Assertiveness was positively related
with self-esteem and two conflict
management styles (collaboration and
competition).
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Table 2: Selected study characteristics in the 1990s
*Study appraisal: 1) the aims and objectives of the research are
clearly stated; 2) the researchers design is clearly specified and
appropriate for the aims and objectives of the research; 3) the
researchers provide a clear account of the process by which their
findings were reproduced; 4) the researchers display enough data to
support their interpretations and conclusions, and 5) the method of
analysis is appropriate and adequately executed.
Nurses’ assertiveness in the 1990s
In the 1990s, larger studies were conducted (Table 2)[10,13,22-24].
A large study reported that nurses in the U.S. appeared more assertive
than non-nurses (e.g. teacher) did [13]. This study demonstrated that
at least one population of nurses (e.g. staff nurses) was assertive, even
when the previous nursing literature assumed that nurses were
typically unassertive. In addition, there was a positive correlation
between academic degree level and assertiveness [23]. This indicates
that the academic degree level of nurses may affect their assertiveness
in this era. Other studies indicated a positive relationship between
assertiveness and self-esteem [21,24]. Self-esteem reflects a person’s
overall emotional evaluation of his or her own worth. These findings
support the role of confidence and self-esteem in enhancing the
assertiveness of nurses.
Nurses’ assertiveness after 2000
Researchers tended to focus on the assertive behaviour of nurses at
work (Table 3) [25-30]. Nurses in fields such as midwifery were found
to be more assertive than some of their colleagues [30]. They suggested
that nurses behave in a passive way, conforming to the stereotype of a
‘nice’ nurse, and were less likely to disagree with the opinions of others
or to provide constructive criticism to others. Fear associated with
communicating effectively in a work setting was not mediated by age
or educational level. In addition, DeMarco et al. found that nurses in a
non-staff role were more assertive than staff nurses [27], but they did
not define a non-staff role. We therefore conclude that the status and
experience of nurses can influence their assertiveness in health care
settings.
Autho
r,
year,
Aim of
study
Sample
size and
Measurem
ents and
analysis
Main results Study
apprais
al*
count
ry
descriptio
n
Garon
[25]
To explore
nurses’
perceptions
of
assertivene
ss
33
registered
nurses in
California.
Focus
group
interviews,
thematic
content
analysis.
Taught at home,
culture and
language, doing
the right thing,
education,
relationship with
peers, managers
and administrative/
executives,
organisational
culture,
transmission and
reception, and
outcomes after
speaking up
influenced
assertiveness.
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Wong
[26]
To test the
relationship
between
leadership
style and
communica
tion
behaviour.
280
registered
nurses
working in
acute care
hospitals.
Authentic
Leadership
Questionna
ire,
Personal
and Social
Identificatio
n, Trust in
Manageme
nt Scale,
Utrecht
Work
Engageme
nt Scale,
Helping
and Voice
Behaviours
Scale,
Internation
al Survey
of Hospital
Staffing,
and
Organizatio
nal of
Patient
Outcomes,
structural
equation
analysis.
Authentic
leadership
significantly
influenced staff
nurses’ trust in
their manager and
work engagement,
which in turn
predicted voice
behaviour and
perceived unit
care quality (χ2 =
17.24, df = 11, p =
0.10, IFI = 0.99,
CFI = 0.99,
RMSEA = 0.045).
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 5 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
DeMar
co [27]
To develop
a scale.
738
registered
nurses in
Massachus
etts.
Silencing
the Self
Scale,
Nurse
Workplace
Scale, and
demograph
ic items,
factor
analysis,
and t-test.
Silencing
behaviour is not
significantly
different by age (p
= 0.28) or
education (p =
0.11). Nurses in a
non-staff role had
lower scores than
did staff nurses (p
< 0.005).
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Timmi
ns &
McCa
be [28]
To describe
the
assertivene
ss of
nurses and
midwives.
1500
nurses and
midwives
registered
with the
National
Nursing
Board of
Ireland.
Original
questionnai
re (44
items):
Assertive
behaviour
to indicate
the
frequency
with which
they use
them with
three
groups of
nursing
colleagues
(nursing
manageme
nt, medical
colleagues
and other
healthcare
staff),
demograph
ic
characterist
ics, open-
ended
questions
of
influencing
factors of
assertivene
ss, content
analysis.
Assertive
behaviour was
used more
frequently with
nursing/midwifery
colleagues than
with management/
medical
colleagues.
Responsibility to
patient and
knowledge
emerged as
supporting factors
for using assertive
behaviour.
Mangers, the work
atmosphere, and
fear were viewed
as obstacles.
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Timmi
ns &
McCa
be [30]
To describe
assertive
behaviour
and the
associated
factors.
27
registered
nurses
from
participants
of nursing
course,
pilot study.
Questionna
ire (44
items,
same as in
Timmins &
McCabe
2005a)
Nurses behave in
a passive way,
conforming to the
image of a ‘nice’
nurse. Colleagues
were frequently
reported as well as
management,
confidence and
the atmosphere in
the workplace as
facilitator of
assertive
behaviour.
1. Yes
2. Yes
3. Yes
4. Weak
5. Yes
Colleagues,
management and
atmosphere were
also reported as
militating factors.
Table 3 : Selected study characteristics after year 2000.
*Study appraisal: 1) the aims and objectives of the research are
clearly stated; 2) the researchers design is clearly specified and
appropriate for the aims and objectives of the research; 3) the
researchers provide a clear account of the process by which their
findings were reproduced; 4) the researchers display enough data to
support their interpretations and conclusions, and 5) the method of
analysis is appropriate and adequately executed.
Several factors have been found as influencing factors of nurses’
assertiveness. A sense of responsibility for patients and nursing
knowledge were correlated with levels of assertiveness [30]. In
addition, leadership qualities in managers, organisational culture, and
relationships between colleagues play an important role in fostering
assertiveness [26,30]. Managers’ leadership positively influenced staff
nurses’ trust in their manager and their engagement in work, which in
turn predicted assertiveness and quality of patient care [26]. In
addition to these factors, nurses expressed concern towards how
colleagues deal with their complaints and issues [25]. Staff nurses
reported that they felt their message was ignored when they expressed
themselves in an emotional way. As a result, they reported feeling
disenfranchised and unimportant, which did not facilitate
assertiveness [25]. They also reported that they wanted to know that
their concerns were taken seriously [25]. In order to enhance the
assertiveness of nurses, it is important for hospital managers and nurse
managers to provide appropriate feedback to nurses regarding their
communication. The home environment, education, and culture can
all influence nurses’ attitudes towards communication [25]. For
example, assertiveness is less likely to be accepted in traditional Asian
families, while American students are encouraged to be assertive [25].
Hospital managers and senior staff members should thus consider
cultural backgrounds when assessing the standard of communication
of staff members.
Effectiveness of assertiveness training
To enhance assertiveness of nurses, the several training
programmes have been conducted through the decades (Table 4)
[31-39]. Most of the studies reported that nurses’ self-reported
assertiveness were improved after the intervention. However, no
studies have evaluated the assertiveness of nurses in a clinical setting.
Future studies should therefore investigate the efficacy of assertiveness
training in a clinical setting.
Author, year, country Sample size and
description
Measurements and analysis Main results Study appraisal*
Raica [31] Nurses (number
unknown).
Pre-post study design, originally developed
communication self-efficacy scale, t-test.
Outcome level: B. After training, the
communication self-efficacy scores increased
significantly in all dimensions.
1. Yes
2. Yes
3. Weak
4. Weak
5. Yes
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 6 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
Yamagishi et al. [32] 26 nurses from an
urban hospital.
Pre-post study design, originally developed
assertion knowledge, Assertive Mind Scale,
Assertion Check List, Job Stress Brief
Questionnaire, Depression from Brief Job
Stress Questionnaire, Wilcoxon signed rank
test.
Outcome level: B to C. Assertion knowledge
and voluntary behaviour in assertive
behaviour had increased at post-training and
remained higher a month later, with regard to
job stress, mental workload also decreased.
1. Yes
2. Yes
3. Yes
4. Weak
5. Yes
Shimizu et al. [33] 45 nurses in a hospital. Pre-post study design, Japanese version of
the Maslach Burnout Inventory, originally
developed Communication skill check-list, t-
test.
Outcome level: B. Personal accomplishment
and two communication skills such as
accepting valid criticism and negotiation of the
intervention group significantly improved five
months after the training (p < 0.05).
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Freeman & Adams [34] 65 nurses in urban
hospitals.
Comparison with reference group, original
Behaviour Inventory Tool, Nurses’
Assertiveness Inventory, t-test.
Outcome level: B. Nurses who had extra
training with behavioural rehearsal of informal
modelling reported increased assertiveness
scores (p < 0.05).
1. Yes
2. Yes
3. Weak
4. Yes
5. Yes
Dunn & Sommer [35] 62 nurses in a medical
centre.
Pre-post study design, original Spinal Cord
Injury Assertiveness Inventory,
Rehabilitation Situations Inventory, ANOVA.
Outcome level: B. Nurses reported a
significant decrease in discomfort of
assertiveness.
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Lee & Crockett [36] 60 nurses in a hospital. Comparison with reference group, Rathus
Assertiveness Schedule, Perceived Stress
Scale, ANOVA.
Outcome level: B. Nurses of training group at
both post training and four weeks later scored
significantly higher on the rating of
assertiveness than those in the alternate
treatment control group.
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Kirkpatrick & Forchuk
[37]
24 nurses in a tertiary
care psychiatric facility.
Pre-post study design, original semantic
differential scale, Assertion Inventory, Power
Apprehension Scale, unknown analysis
method.
Outcome level: B. Assertive training does
change nurses’ perceptions of their
assertiveness, as well as functioning within a
nursing team and functioning within a
multidisciplinary team.
1. Yes
2. Yes
3. Yes
4. Weak
5. Weak
McIntyre et al. [38] 26 nurses in a hospital. Comparison with reference group,
Assertiveness Self-statement Test, Rathus
Assertiveness Schedule, Adult Self-
expression Scale, t-test; Observation: two
Likert scales for self-rating and role-play
observation, ANOVA.
Outcome level: B. After training, intervention
group members significantly increased their
levels of assertiveness, as indicated on the
self-report tests (p < 0.05); role-play ratings
supported the self-report results (p < 0.05).
1. Yes
2. Yes
3. Yes
4. Yes
5. Yes
Dunham & Brower1984,
USA [39]
59 nurses from a
practitioner
program.
Pre-post study design, Assertion Inventory,
original degree nurse attitudes towards
assertiveness, t-test.
Outcome level: B. The training had a
significant impact on attitude towards
assertiveness.
1. Yes
2. Yes
3. Weak
4. Yes
5. Yes
Table 4: Selected study characteristics of assertiveness training.
*Study appraisal: 1) the aims and objectives of the research are
clearly stated; 2) the researchers use comparative study design; 3) the
researchers provide a clear account of the process by which their
findings were reproduced, including allocating the participants
appropriately; 4) the researchers display Kirkpatrick outcome level (A
learners’ view on its intervention; B self-assessed modification of
learner; C transfer of learning, in other words an objectively measured
change in learner or observer knowledge or skills; D results in terms of
a change in quality of patient care) and enough data to support their
interpretations and conclusions, and 5) the method of analysis is
appropriate and adequately executed.
Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 7 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
The possible strategy for enhancing nurses’ assertiveness
Recently the number of nurses who educated at higher academic
level increased. The studies conducted after 2000 suggested that nurses
behave in a passive way, conforming to the stereotype of a ‘nice’ nurse,
and were less likely to disagree with the opinions of others or to
provide constructive criticism to others. Nurses are expected to help
bridge the gap between coverage and access, to coordinate increasingly
complex care for a wide range of patients [10]. Nurse should
understand these roles as a professional and should be educated
nursing knowledge in order to provide patient appropriate care.
Several contextual factors were reported as influencing factors of
nurses’ assertiveness, including leadership qualities in managers,
organisational culture, and relationships between colleagues [26,30].
Nurses concern towards how their colleagues react to their issues and
complaints. It is very important to provide appropriate feedback safety
in order to avoid fear for conflicts. Managers are expected to show
leadership to provide a safe environment that enhances nurses’ trust.
Moreover, nurse’ personal also influence nurses’ assertiveness. For
effective team working, we should respect the cultural backgrounds of
other team members.
The present authors searched for English language articles, and
most of the studies that were included in the review were carried out in
the U.S. Therefore, our findings cannot be simply generalised in other
nurses’ communities with different cultural background. Nurses may
have different roles in other countries. In addition, some studies, in
particular studies conducted in 1970s and 1980s, have significant
threats to validity including self-selection bias, response bias on self-
reported measures. We should interrupt these results carefully.
Conclusion
This article provides an overview of the studies on nurses’
assertiveness. In the 1970s and 1980s, educational achievement was
regarded as a key factor in nurses’ assertiveness. However, the number
of nurses who are trained in higher educational institutions has
increased. Des pite this, nurses still experience some difficulties to be
assertive themselves. Nurse should understand their role at the recent
health care environment as a professional. Nurses’ concerns about
their colleagues’ response to voice are also an important factor for
deciding nurses’ voicing. Nurse managers should take a leadership to
avoid nurses’ concerns about voicing their opinions with respecting
nurses’ cultural background.
Acknowledgements
We would like to thank the pre-medical librarian Mr. Swa at Osaka
University Life Sciences Library in Japan for assistance with the
literature search. He did not receive compensation for his efforts
beyond his usual salary.
Funding and Conflict Of Interest
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors. No conflict of
interest has been declared by the authors.
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Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194
Page 9 of 9
J Nurs Care
ISSN:2167-1168 JNC, an open access journal
Volume 3 • Issue 5 • 1000194
- Contents
- How We Can Enhance Nurses’ Assertiveness: A Literature Review
- Abstract
- Keywords:
- Introduction
- Methods
- Results and Discussion
- Nurses’ assertiveness in the 1970s and 1980s
- Nurses’ assertiveness in the 1990s
- Nurses’ assertiveness after 2000
- Effectiveness of assertiveness training
- The possible strategy for enhancing nurses’ assertiveness
- Conclusion
- Acknowledgements
- Funding and Conflict Of Interest
- References
