Nurse Education in Practice 14 (2014) 752e756
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education in practice
Assertiveness training for undergraduate midwifery students Jane Warland*, Lois McKellar, Monica Diaz School of Nursing and Midwifery, University of South Australia, Adelaide, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 23 September 2014
Assertiveness can be defined as an interpersonal behaviour that promotes the fact all people in a relationship are equally important. All health professionals including midwives must work with and care for people. At times this will include facilitating interactions that require skilful negotiation and assertiveness. Yet embedding assertiveness education into undergraduate midwifery curricula has not been widely adopted. This paper explores one method of delivering assertiveness training in an undergraduate midwifery course and provides comment on the effectiveness of this strategy in developing assertiveness skills in a cohort of undergraduate midwifery students. We used an assertiveness survey which was administered immediately before and 3e4 months after an assertiveness training workshop. All students (n ¼ 55) attending the training day were invited to participate. Of these 41 (77% response) chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in the follow up survey. There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. These findings provide encouraging evidence that educational institutions that offer specific and targeted assertiveness education will be rewarded with more assertive graduates. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Assertiveness Undergraduate education Midwifery
Background Assertiveness can be defined as an interpersonal behaviour that maintains boundaries whilst allowing people in relationship to express their needs clearly and directly. Assertive behaviour is seen when an individual gives expression to their rights, thoughts and feelings in a way that does not degrade but recognises and respects the rights, thoughts and feelings of others (Begley and Glacken, 2004; Slater, 1990). Assertiveness may sometimes be confused with aggression, particularly in the workplace. However, the main difference between assertiveness and aggression is in the approach taken to a situation or problem. A person exhibiting assertive behaviour will tackle the problem rather than the person, so that all involved are respected (Slater, 1990). In contrast, a person exhibiting aggressive behaviour will have little regard for the thoughts and feelings of
* Corresponding author. School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia. Tel.: þ61 08 83021161; fax: þ61 08 83022168. E-mail address: [email protected] (J. Warland). http://dx.doi.org/10.1016/j.nepr.2014.09.006 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
others in their quest to achieve a solution to a problem (Slater, 1990). A positive correlation exists between assertiveness, job satisfaction and role clarity (Lounsbury et al., 2003) as well as the ability to deal with stress and bullying in the workplace. Assertiveness skills therefore, can be used to counteract workplace bullying, as well as ameliorate stressful situations and increase empowerment (Begley, Glacken, 2004). There have been a few studies exploring the benefits of assertive behaviour for nurses, (Kilkus, 1993; Lawton, Stewart, 2005; Sudha, 2005) however, this is less well explored in the midwifery profession. One of the core competencies of a registered midwife is to act as an advocate to protect the rights of woman in relation to maternity care (NMBA, 2006). This involves acknowledging and respecting the woman's right to be involved as an active participant in her care as well as advocating for her as she makes decisions, whilst maintaining her dignity and privacy. Therefore, the ability to be assertive when advocating for women is key to the midwife's role. At times this will include facilitating interactions that require skilful negotiation and assertiveness. It is not uncommon to find midwives dealing with highly aroused partners and/or family members, as well as having to support and look after the needs of the woman herself and deal assertively with colleagues. In order for
J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756
midwifery students to be well prepared for their role as a midwife it is important that they are equipped with skills to safely manage their own behaviour and the behaviour of others. Midwifery is a predominately female profession. Femininity has been traditionally associated with non-assertiveness, caring and nurturing behaviours, however, the role of a midwife is also professional and autonomous. These factors may act to reduce a midwife's capacity to behave in an assertive manner (Timmins and McCabe, 2005a, b). As nurses and midwives move away from traditional stereotypes (Jinks and Bradley, 2004), it is increasingly being recognized that caring and assertive behaviours can co-exist (McCartan; Hargie, 2004). Indeed, much literature supports the fact that assertive behaviour in clinical practice enables effective safe professional communication (Garon, 2012) as well as a sense of personal empowerment (Laschinger et al., 2009). Although specific individual assertive behaviours and skills have been examined in many settings, little empirical evidence exists about the manner in which assertive skills are acquired and used by nurses and midwives in the workplace. Those studies which have been conducted indicate that assertiveness skills are not necessarily innate and therefore, may be learned (Arslan et al., 2013; Kilpatrick, Forchuk, 1992; Lee, Crockett, 1994; Lin et al., 2004.) This paper explores one method of delivering assertiveness training in an undergraduate midwifery course. We provide comment on the effectiveness of this strategy in developing assertiveness skills in a cohort of undergraduate midwifery students. Instrument Following a review of the relevant literature, we identified several assertiveness scales (Galassi et al., 1974; Gambrill, Richey, 1975; Rathus, 1973). We chose an assertiveness questionnaire developed by Begley and Glacken (2004) which had been specifically created for use with Irish undergraduate nursing students. We adapted it for use with undergraduate midwifery students by changing the word “patient” to “woman.” The questionnaire included 28, 4 point Likert questions with the options ‘always’, ‘often’, ‘rarely’ and ‘never’. The questions were designed to determine students' current level of assertiveness both in the workplace and in social settings and had been validated both by the developers (Begley& Glacken, 2004) and through a similar study to ours (Deltsidou, 2009). In addition to the assertiveness questionnaire students were also asked their age range and enrolment status (i.e. domestic or international). Approach The study was designed to measure midwifery student's assertiveness immediately prior to the start of the one-day assertiveness training workshop and assess whether or not this changed when the students returned to the University after a clinical placement. A pre and post intervention survey was administered. The first baseline survey was administered face-to-face immediately prior to the workshop commencing. A second post-intervention survey consisting of the same questions was administered when students attended University for their post clinical placement debrief workshop. This workshop occurred approximately three to four months after the assertiveness training workshop. The workshop Assertiveness training programmes are designed to improve an individual's assertive beliefs and behaviours, which can help the individual change how they view themselves and establish selfconfidence and reduce social anxiety (Lin et al., 2008). The
753
workshop was run by the Principal Consultant of a local Counselling and Consultancy Service. She holds qualifications in social work, and has extensive experience in facilitating such training. The one day workshop consisted of: lectures, role-plays, and facilitated discussion. Topics included:
Definition of assertiveness Overcoming difficulties in becoming assertive Steps in giving assertive criticism The role of emotional intelligence, stress, fear, control, power, respect, self-confidence, and resilience in determining assertiveness Role plays included small groups practising:
differentiating between assertive, non-assertive and aggressive verbal and non-verbal behaviour assertively: B telling others how they felt B expressing negative feelings Groups discussed the following over the course of the day: identifying stereotypes (especially female) the influence of positional power on one's ability to assert oneself what can influence people's views of assertive communication discussion of a coroner's report (Lock, 2012) in which the midwives involved did not respond assertively to the emerging situation and a baby died as a result (Table 1). The facilitator of the workshop also conducted a workshop evaluation using satisfaction measures. Students were given six evaluation questions which asked for their response using5 point Likert scales. 41 students (77% response) participated in the evaluation survey. There was greater than 98% broad agreement (Strongly agree/Agree) on all questions with the remaining 1 or 2 students holding a neutral opinion (Table 2). Population The sample population consisted of 53 students. The students were mainly “direct entry” students, “registered nurses” undertaking our undergraduate midwifery program receive “credit” for this course. All students attending the workshop were invited to participate. Of these 41 (77% response) chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in the follow-up survey after their clinical placement. Table 1 Participant demographics. n ¼ 41 (%) Age group 19e24 years 25e30 years 31e36 years 37e42 years >43 years Missing Enrolment status International student Domestic student Missing All were female.
23 6 3 5 2 2
(56) (15) (7) (12) (5) (5)
4 (10) 34(83) 3 (7)
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J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756
Table 2 Workshop participation evaluation data.
Table 3 Assertiveness scores.
Question
5 (High)
4
Subject matter Interest level Objectives Presentation Learning value Participant involvement
34 22 28 31 23 29
7 18 13 8 17 10
3 1 2 1 2
2
1 (low)
Total 41 41 41 41 41 41
Ethical considerations Ethics approval was gained from the University's Human Research Ethics Committee. Shortly before the workshop began the students were informed about the study by one of the investigators (JW). Those who indicated they were interested were given a participant information sheet and if they were still interested they completed a consent form and the questionnaire. Students were reassured that their participation was not compulsory, and that their grade for the unit would not be affected, either by their participation or non-participation. The assertiveness training workshop was not linked in any way with unit assessment. Data analysis The assertiveness ‘score’ was calculated by allocating 1 to 4 points to the answers to each question (Table 3) where 1 was allocated to an unassertive answer and 4 for the most assertive answer to each question. Most questions scored 1 for always and 4 for never, however, some questions were reverse scored when “always” was the most assertive answer. The reversed scored questions are indicated in bold on Table 3. The higher the students scored the more assertive they perceived themselves to be. Data were entered into SPSS version 19. Mean assertiveness scores were calculated and comparisons made between students' responses pre and post workshop using ManneWhitney U. Results Pre workshop assertiveness scores Prior to the workshop the mean assertiveness score was 68.8 (range 53e92) (Table 3). The lowest mean score was to question 15 (I am careful to avoid hurting other people's feelings). The highest mean score for all questions was to question 3 (I find it difficult to compliment and praise friends and acquaintances) (Table 3). Note this was a reverse scored question indicating that the participants considered that they rarely or never found this difficult. Post workshop assertiveness scores Following the workshop the mean assertiveness score was 75.5 (range 62e99). The lowest mean score remained with question 15. The highest mean score for all questions was to question 9 (I would feel uncomfortable paying a compliment to a junior colleague). The mean score for this question was close to 4, indicating that most participants had answered “never” to this reverse scored question.
Question
Time
Average score
Exact sig. (2 tailed)
1. At work I tend to keep my feelings to myself 2. I feel uncomfortable asking a colleague to do a favour for me 3. I find it difficult to compliment and 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 work place 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 was 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 14. I try to avoid conflict at work
Pre Post Pre Post
2.1 2.3 2.4 2.8
0.225
Pre Post
3.5 3.6
0.393
Pre Post
2.6 2.9
0.067
Pre Post
2.5 2.95
0.009*
Pre Post Pre Post Pre Post
2.4 2.6 3.3 3.6 2.5 2.9
0.276
Pre Post Pre Post Pre Post
3.5 3.7 1.6 1.65 2.75 2.95
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
2.5 2.7 2.1 2.3 1.6 1.8 1.5 1.6 2.7 2.5 2.7 3.0 3.1 3.3
Pre Post
2.5 2.5
0.978
Pre Post
2.2 2.4
0.328
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
2.6 3.0 2.65 2.9 2.5 2.7 2.8 3.4 2.1 2.2 1.95 2.3 1.8 2.0 2.45 2.6
0.008*
15. I am very careful to avoid hurting other people's feelings 16. In a group I make the decisions 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 upsets a woman (client), 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 favours for me 23. When someone pays me a compliment, I feel unsure of what to say 24. If I was impressed by the actions of a senior colleague, I would tell him/her 25. I tend to be over-apologetic to colleagues 26. I tend to be over-concerned about my woman's (client) welfare 27. I would feel uncomfortable expressing annoyance at a senior colleague 28. I am a follower, rather than a leader
0.011*
0.053 0.039*
0.248 0.730 0.193
0.234 0.385 0.262 0.256 0.506 0.019* 0.282
0.145 0.346 0.001* 0.487 0.029* 0.280 0.270
Bold text is reversed scored.
Overall assertiveness scores Overall the mean assertiveness scores prior to the workshop was 68.8 and this improved to 75.5 (p ¼ .0002) following the workshop. There was an improved score noted to 26 of the 28 individual questions between the pre and post-test, with the mean
score for question 19 remaining the same and the mean score for question 16 dropping slightly. When examining the statistically significant changes to individual questions there was a general tendency for the students to report increased level of assertiveness
J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756
pre and post the workshop, however, this change was only statistically significant to questions 2, 5, 8, 17, 21, 24 and 26 (Table 3). Of importance is the significant improvement (p ¼ .008) to question 21 “At work I avoid asking questions for fear of sounding stupid” as well as question 24 (p ¼ .001) “If I was impressed by the actions of a senior colleague, I would tell him/her.” Age We divided the cohort into two age groups one under (n ¼ 23) and the other over (n ¼ 17) 25 years of age (1 student did not give her age and so was excluded from this analysis). There was a statistically significant (p ¼ .005) improvement in mean assertiveness score (from 68.15 to 75.49) in the students who were less than 25. Whilst there was also an improvement in the overall mean score in the group who were older than 25 (from 69 to 73.5) this was not statistically significant (Table 4). There was no difference between perceived areas of strengths and weaknesses in assertiveness with both age groups, having question 15 as their lowest score prior to the workshop and question 9 as the most assertive both before and after the workshop. Discussion There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. This provides encouraging evidence that educational institutions that provide specific and targeted assertiveness education will be rewarded with more assertive graduates. The link between assertiveness and maturity is well understood (Goldman and Olczak, 1981; Twenge, 2001). However, when this was assessed we found a statistically significant improvement in the younger students' scores and whilst there was also an improvement in the overall assertiveness score in the older group this was not statistically significant. As the over 25's did not start with a higher score this may indicate that the older student is more resistant to change. Alternatively the type of training may have better suited the younger students. Whatever the reason it would be important for future research to assess how to better facilitate the needs of older students as they learn this vital skill. When learning assertiveness, some students may have to wrestle with cultural mores and expectations from their family of origin and education (Hijazi et al., 2011). Much of their earlier socialisation may have been based on what others expected that they 'should', 'ought', 'must' do, with some having little opportunity prior to the workshop to develop assertive skills (Hijazi et al., 2011). Unfortunately the numbers of international (mainly Asian and South East Asian) students in the cohort were too small (n ¼ 4) to determine any distinct cultural difference in this groups' assertiveness levels. Further research to determine the effect of an assertiveness training for these students is therefore warranted.
Table 4 Comparison of overall and age related mean level of assertiveness pre and 3 months post assertiveness workshop. Group
Time
Mean score
n
Minimum score
Maximum score
Exact sig. (2-tailed)
Overall score
Pre Post Pre Post Pre Post
68.8 75.5 68.15 75.49 68.8 73.5
39 29 23 17 14 12
53 62 53 62 56 62
92 99 92 99 83.5 86
0.002*
Age less than 25 Age older than 25
0.005* 0.171
755
Howard (2001) noted that improved assertiveness may impact negatively on the students' personal and social lives. With Mc Cabe and Timmins (2003) going so far as to suggest that the students may need to be supported as they learn to deal with such issues. In this study students appeared to find new confidence in the workplace as demonstrated by their significantly improved responses to questions 21 and 24. Many students also reflected their positive evaluation of the workshop on their personal life by making comments such as: “I identified that I need to be more confident and actually know when to step up and express my concerns when necessary without undermining my peer's authority. It was useful for my personal growth” “I believe this training is very useful as it will allow me to better my assertiveness when working in the work place as well as my personal life.” Identified barriers that may prevent nurses from being assertive include lack of knowledge about personal/professional rights, concern about what others will think about their behaviour and anxiety due to a lack of confidence and poor self-esteem (Poroch and McIntosh, 1995). Our study demonstrated an improvement in understanding rights in a group who already seemed to understand these rights (pre score 3.3 to post score 3.6: maximum score 4). We also found a significant improvement in students being prepared to ask questions, even if this was at the expense of “sounding stupid.” It would therefore appear that our students may have overcome some of the barriers to becoming assertive.
Limitations It is recognised that there would be a natural improvement in assertiveness over time, with both life experience and maturity. However, the improvement in the overall perceived assertiveness score in this study occurred over a relatively short period of time (relative to a life-time) and thus most of the improvement can probably be attributed to the specific education on assertiveness the students received. The assertiveness education package was one developed by an individual consultant especially for our students, therefore the study may not be easily replicated in other schools of Nursing and Midwifery, neither are the results necessarily generalizable to other Nursing and Midwifery schools. Those students who did not complete the post-workshop survey could perhaps be assumed to be less assertive than those who chose to remain in the study and if this was the case their nonparticipation could have been responsible for the increase in assertiveness score. However, the mean assertiveness score of those who did not participate in the post workshop survey was actually a little higher (69.18) than the remaining respondents, indicating that if these students had participated the postworkshop score could have been even higher.
Conclusions Assertiveness is an important skill for midwives to develop. Holding these skills enables midwives to advocate for the woman, improves inter-professional communication, and personal confidence. Providing assertiveness training is therefore an important part of any undergraduate midwifery programme. However, dedicated assertiveness training is not always part of higher education and can be costly.
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J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756
Although the benefits of teaching this topic have not yet been empirically tested, our pre and post intervention study demonstrates that there are significant and immediate benefits for student midwives, especially in gaining confidence in asking questions and not being afraid to compliment their superiors on a job well done. Whilst our students reported feeling more assertive this may not necessarily translate to changed personal behaviours in the clinical environment. It would be important for future studies to explore this and also if there are any barriers to change that the students experience when they attempt to put assertive skills into practice. Further research is also required to determine more effective methods for enabling older students to improve their assertiveness scores. More research is also needed on whether or not different cultural groups require a different approach when teaching them these skills. Outlining how we approached this particular teaching session may prove to be a useful guide for those involved in teaching assertiveness to undergraduate midwifery students. Overall the students evaluated the workshop as valuable and we found that they self-reported increased assertiveness scores three months following the assertiveness training workshop. Acknowledgements Students undertaking the perinatal mental health course in 2013: for generously agreeing to take part in this research during a very busy year. Maurissa Ailion who designed and delivered the assertiveness training. Prof Adrian Esterman for his assistance with data analysis. References Arslan, E., Akca, K.N., Baser, M., 2013. Levels of assertiveness and peer pressure of nursing students. Int. J. caring Sci. 6 (1), 78e86. Begley, C.M., Glacken, M., 2004. Irish nursing students' changing levels of assertiveness during their pre-registration programme. Nurse Educ. Today 24 (7), 501e510. Deltsidou, A., 2009. Undergraduate nursing students' level of assertiveness in Greece: a questionnaire survey. Nurse Educ. Pract. 9 (5), 322e330. Galassi, J.P., DeLo, J.S., Galassi, M.D., Bastein, S., 1974. The college self-expression scale: a measure of assertiveness. Behav. Ther. 5 (2), 165e171. Gambrill, E.D., Richey, C.A., 1975. An assertion inventory for use in assessments and research. Behav. Ther. 6 (4), 550e561. Garon, M., 2012. Speaking up, being heard: registered nurses' perceptions of workplace communication. J. Nurs. Manag. 20 (3), 361e371.
Goldman, J., Olczak, P., 1981. The relationship between psychosocial maturity and assertiveness in males and females. J. Youth Adolesc. 10 (1), 33e44. Hijazi, A., Tavakoli, S., Slavin-Spenny, O., Lumley, M., 2011. Targeting interventions: moderators of the effects of expressive writing and assertiveness training on the adjustment of international University students. Int. J. Adv. Couns. 33 (2), 101e112. Howard, D., 2001. Student nurses experiences of project 2000. Nurs. Stand. 15 (48), 33e38. Kilkus, S.P., 1993. Assertiveness among professional nurses. J. Adv. Nurs. 18 (8), 1324e1330. Kilpatrick, H., Forchuk, C., 1992. Assertiveness training: does it make a difference? J. Nurs. Staff Dev. 8 (2), 60e65. Laschinger, H.K.S., Leiter, M., Day, A., Gilin, D., 2009. Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcomes. J. Nurs. Manag. 17 (3), 302e311. Lawton, S., Stewart, F., 2005. Assertiveness: making yourself heard in district nursing. Br. J. Community Nurs. 10 (6), 281e283. Lee, S., Crockett, M.S., 1994. Effect of assertiveness training on levels of stress and assertiveness experienced by nurses in Taiwan, Republic of China. Issues Ment. Health Nurs. 15 (4), 419e432. Lin, Y.-R., Shiah, I.-S., Chang, Y.-C., Lai, T.-J., Wang, K.-Y., Chou, K.-R., 2004. Evaluation of assertiveness training program on nursing and medical students' assertiveness, self esteem, and interpersonal communication satisfaction. Nurse Educ. Today 24 (8), 656e665. Lin, Y.-R., Wu, M.-H., Yang, C.-I., Chen, T.-H., Hsu, C.-C., Chang, Y.-C., Tzeng, W.-C., Chou, Y.-H., Chou, K.-R., 2008. Evaluation of assertiveness training for psychiatric patients. J. Clin. Nurs. 17 (21), 2875e2883. Lock, J., 2012. Inquest into the Death of Preston Paudel. Coroners Court, Toowoomba and Brisbane. Retrieved 26th March 2014. http://www.courts.qld.gov.au/__ data/assets/pdf_file/0005/165470/cif-paudel-p-20121025.pdf. Lounsbury, J.W., Loveland, J.M., Sundstrom, E.D., Gibson, L.W., Drost, A.W., Hamrick, F.L., 2003. An investigation of personality traits in relation to career satisfaction. J. Career Assess. 11 (3), 287e307. Mc Cabe, C., Timmins, F., 2003. Teaching assertiveness to undergraduate nursing students. Nurse Educ. Pract. 3 (1), 30e42. McCartan, P.J., Hargie, O.D.W., 2004. Assertiveness and caring: are they compatible? J. Clin. Nurs. 13 (6), 707e713. NMBA, 2006. National Competency Standards for the Midwife. Nursing and Midwifery Board of Australia. Retrieved 26th March 2014. http://www. nursingmidwiferyboard.gov.au. Poroch, D., McIntosh, W., 1995. Barriers to assertive skills in nurses. Aust. N. Z. J. Ment. Health Nurs. 4 (3), 113e123. Rathus, S.A., 1973. A 30-item schedule for assessing assertive behavior. Behav. Ther. 4, 398e406. Slater, J., 1990. Effecting personal effectiveness: assertiveness training for nurses. J. Adv. Nurs. 15, 337e356. Sudha, R., 2005. How to be an assertive nurse? Nurs. J. India 96 (8), 182e183. Timmins, F., McCabe, C., 2005a. How assertive are nurses in the workplace? A preliminary pilot study. J. Nurs. Manag. 13 (1), 61e67. Timmins, F., McCabe, C., 2005b. Nurses' and midwives' assertive behaviour in the workplace. J. Adv. Nurs. 51 (1), 38e45. Twenge, J.M., 2001. Changes in women's assertiveness in response to status and roles: a cross-temporal meta-analysis, 1931e1993. J. Person. Soc. Psychol. 81 (1), 133e145.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education in practice
Assertiveness training for undergraduate midwifery students Jane Warland*, Lois McKellar, Monica Diaz School of Nursing and Midwifery, University of South Australia, Adelaide, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 23 September 2014
Assertiveness can be defined as an interpersonal behaviour that promotes the fact all people in a relationship are equally important. All health professionals including midwives must work with and care for people. At times this will include facilitating interactions that require skilful negotiation and assertiveness. Yet embedding assertiveness education into undergraduate midwifery curricula has not been widely adopted. This paper explores one method of delivering assertiveness training in an undergraduate midwifery course and provides comment on the effectiveness of this strategy in developing assertiveness skills in a cohort of undergraduate midwifery students. We used an assertiveness survey which was administered immediately before and 3e4 months after an assertiveness training workshop. All students (n ¼ 55) attending the training day were invited to participate. Of these 41 (77% response) chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in the follow up survey. There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. These findings provide encouraging evidence that educational institutions that offer specific and targeted assertiveness education will be rewarded with more assertive graduates. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Assertiveness Undergraduate education Midwifery
Background Assertiveness can be defined as an interpersonal behaviour that maintains boundaries whilst allowing people in relationship to express their needs clearly and directly. Assertive behaviour is seen when an individual gives expression to their rights, thoughts and feelings in a way that does not degrade but recognises and respects the rights, thoughts and feelings of others (Begley and Glacken, 2004; Slater, 1990). Assertiveness may sometimes be confused with aggression, particularly in the workplace. However, the main difference between assertiveness and aggression is in the approach taken to a situation or problem. A person exhibiting assertive behaviour will tackle the problem rather than the person, so that all involved are respected (Slater, 1990). In contrast, a person exhibiting aggressive behaviour will have little regard for the thoughts and feelings of
* Corresponding author. School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia. Tel.: þ61 08 83021161; fax: þ61 08 83022168. E-mail address: [email protected] (J. Warland). http://dx.doi.org/10.1016/j.nepr.2014.09.006 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
others in their quest to achieve a solution to a problem (Slater, 1990). A positive correlation exists between assertiveness, job satisfaction and role clarity (Lounsbury et al., 2003) as well as the ability to deal with stress and bullying in the workplace. Assertiveness skills therefore, can be used to counteract workplace bullying, as well as ameliorate stressful situations and increase empowerment (Begley, Glacken, 2004). There have been a few studies exploring the benefits of assertive behaviour for nurses, (Kilkus, 1993; Lawton, Stewart, 2005; Sudha, 2005) however, this is less well explored in the midwifery profession. One of the core competencies of a registered midwife is to act as an advocate to protect the rights of woman in relation to maternity care (NMBA, 2006). This involves acknowledging and respecting the woman's right to be involved as an active participant in her care as well as advocating for her as she makes decisions, whilst maintaining her dignity and privacy. Therefore, the ability to be assertive when advocating for women is key to the midwife's role. At times this will include facilitating interactions that require skilful negotiation and assertiveness. It is not uncommon to find midwives dealing with highly aroused partners and/or family members, as well as having to support and look after the needs of the woman herself and deal assertively with colleagues. In order for
J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756
midwifery students to be well prepared for their role as a midwife it is important that they are equipped with skills to safely manage their own behaviour and the behaviour of others. Midwifery is a predominately female profession. Femininity has been traditionally associated with non-assertiveness, caring and nurturing behaviours, however, the role of a midwife is also professional and autonomous. These factors may act to reduce a midwife's capacity to behave in an assertive manner (Timmins and McCabe, 2005a, b). As nurses and midwives move away from traditional stereotypes (Jinks and Bradley, 2004), it is increasingly being recognized that caring and assertive behaviours can co-exist (McCartan; Hargie, 2004). Indeed, much literature supports the fact that assertive behaviour in clinical practice enables effective safe professional communication (Garon, 2012) as well as a sense of personal empowerment (Laschinger et al., 2009). Although specific individual assertive behaviours and skills have been examined in many settings, little empirical evidence exists about the manner in which assertive skills are acquired and used by nurses and midwives in the workplace. Those studies which have been conducted indicate that assertiveness skills are not necessarily innate and therefore, may be learned (Arslan et al., 2013; Kilpatrick, Forchuk, 1992; Lee, Crockett, 1994; Lin et al., 2004.) This paper explores one method of delivering assertiveness training in an undergraduate midwifery course. We provide comment on the effectiveness of this strategy in developing assertiveness skills in a cohort of undergraduate midwifery students. Instrument Following a review of the relevant literature, we identified several assertiveness scales (Galassi et al., 1974; Gambrill, Richey, 1975; Rathus, 1973). We chose an assertiveness questionnaire developed by Begley and Glacken (2004) which had been specifically created for use with Irish undergraduate nursing students. We adapted it for use with undergraduate midwifery students by changing the word “patient” to “woman.” The questionnaire included 28, 4 point Likert questions with the options ‘always’, ‘often’, ‘rarely’ and ‘never’. The questions were designed to determine students' current level of assertiveness both in the workplace and in social settings and had been validated both by the developers (Begley& Glacken, 2004) and through a similar study to ours (Deltsidou, 2009). In addition to the assertiveness questionnaire students were also asked their age range and enrolment status (i.e. domestic or international). Approach The study was designed to measure midwifery student's assertiveness immediately prior to the start of the one-day assertiveness training workshop and assess whether or not this changed when the students returned to the University after a clinical placement. A pre and post intervention survey was administered. The first baseline survey was administered face-to-face immediately prior to the workshop commencing. A second post-intervention survey consisting of the same questions was administered when students attended University for their post clinical placement debrief workshop. This workshop occurred approximately three to four months after the assertiveness training workshop. The workshop Assertiveness training programmes are designed to improve an individual's assertive beliefs and behaviours, which can help the individual change how they view themselves and establish selfconfidence and reduce social anxiety (Lin et al., 2008). The
753
workshop was run by the Principal Consultant of a local Counselling and Consultancy Service. She holds qualifications in social work, and has extensive experience in facilitating such training. The one day workshop consisted of: lectures, role-plays, and facilitated discussion. Topics included:
Definition of assertiveness Overcoming difficulties in becoming assertive Steps in giving assertive criticism The role of emotional intelligence, stress, fear, control, power, respect, self-confidence, and resilience in determining assertiveness Role plays included small groups practising:
differentiating between assertive, non-assertive and aggressive verbal and non-verbal behaviour assertively: B telling others how they felt B expressing negative feelings Groups discussed the following over the course of the day: identifying stereotypes (especially female) the influence of positional power on one's ability to assert oneself what can influence people's views of assertive communication discussion of a coroner's report (Lock, 2012) in which the midwives involved did not respond assertively to the emerging situation and a baby died as a result (Table 1). The facilitator of the workshop also conducted a workshop evaluation using satisfaction measures. Students were given six evaluation questions which asked for their response using5 point Likert scales. 41 students (77% response) participated in the evaluation survey. There was greater than 98% broad agreement (Strongly agree/Agree) on all questions with the remaining 1 or 2 students holding a neutral opinion (Table 2). Population The sample population consisted of 53 students. The students were mainly “direct entry” students, “registered nurses” undertaking our undergraduate midwifery program receive “credit” for this course. All students attending the workshop were invited to participate. Of these 41 (77% response) chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in the follow-up survey after their clinical placement. Table 1 Participant demographics. n ¼ 41 (%) Age group 19e24 years 25e30 years 31e36 years 37e42 years >43 years Missing Enrolment status International student Domestic student Missing All were female.
23 6 3 5 2 2
(56) (15) (7) (12) (5) (5)
4 (10) 34(83) 3 (7)
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Table 2 Workshop participation evaluation data.
Table 3 Assertiveness scores.
Question
5 (High)
4
Subject matter Interest level Objectives Presentation Learning value Participant involvement
34 22 28 31 23 29
7 18 13 8 17 10
3 1 2 1 2
2
1 (low)
Total 41 41 41 41 41 41
Ethical considerations Ethics approval was gained from the University's Human Research Ethics Committee. Shortly before the workshop began the students were informed about the study by one of the investigators (JW). Those who indicated they were interested were given a participant information sheet and if they were still interested they completed a consent form and the questionnaire. Students were reassured that their participation was not compulsory, and that their grade for the unit would not be affected, either by their participation or non-participation. The assertiveness training workshop was not linked in any way with unit assessment. Data analysis The assertiveness ‘score’ was calculated by allocating 1 to 4 points to the answers to each question (Table 3) where 1 was allocated to an unassertive answer and 4 for the most assertive answer to each question. Most questions scored 1 for always and 4 for never, however, some questions were reverse scored when “always” was the most assertive answer. The reversed scored questions are indicated in bold on Table 3. The higher the students scored the more assertive they perceived themselves to be. Data were entered into SPSS version 19. Mean assertiveness scores were calculated and comparisons made between students' responses pre and post workshop using ManneWhitney U. Results Pre workshop assertiveness scores Prior to the workshop the mean assertiveness score was 68.8 (range 53e92) (Table 3). The lowest mean score was to question 15 (I am careful to avoid hurting other people's feelings). The highest mean score for all questions was to question 3 (I find it difficult to compliment and praise friends and acquaintances) (Table 3). Note this was a reverse scored question indicating that the participants considered that they rarely or never found this difficult. Post workshop assertiveness scores Following the workshop the mean assertiveness score was 75.5 (range 62e99). The lowest mean score remained with question 15. The highest mean score for all questions was to question 9 (I would feel uncomfortable paying a compliment to a junior colleague). The mean score for this question was close to 4, indicating that most participants had answered “never” to this reverse scored question.
Question
Time
Average score
Exact sig. (2 tailed)
1. At work I tend to keep my feelings to myself 2. I feel uncomfortable asking a colleague to do a favour for me 3. I find it difficult to compliment and 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 work place 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 was 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 14. I try to avoid conflict at work
Pre Post Pre Post
2.1 2.3 2.4 2.8
0.225
Pre Post
3.5 3.6
0.393
Pre Post
2.6 2.9
0.067
Pre Post
2.5 2.95
0.009*
Pre Post Pre Post Pre Post
2.4 2.6 3.3 3.6 2.5 2.9
0.276
Pre Post Pre Post Pre Post
3.5 3.7 1.6 1.65 2.75 2.95
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
2.5 2.7 2.1 2.3 1.6 1.8 1.5 1.6 2.7 2.5 2.7 3.0 3.1 3.3
Pre Post
2.5 2.5
0.978
Pre Post
2.2 2.4
0.328
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
2.6 3.0 2.65 2.9 2.5 2.7 2.8 3.4 2.1 2.2 1.95 2.3 1.8 2.0 2.45 2.6
0.008*
15. I am very careful to avoid hurting other people's feelings 16. In a group I make the decisions 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 upsets a woman (client), 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 favours for me 23. When someone pays me a compliment, I feel unsure of what to say 24. If I was impressed by the actions of a senior colleague, I would tell him/her 25. I tend to be over-apologetic to colleagues 26. I tend to be over-concerned about my woman's (client) welfare 27. I would feel uncomfortable expressing annoyance at a senior colleague 28. I am a follower, rather than a leader
0.011*
0.053 0.039*
0.248 0.730 0.193
0.234 0.385 0.262 0.256 0.506 0.019* 0.282
0.145 0.346 0.001* 0.487 0.029* 0.280 0.270
Bold text is reversed scored.
Overall assertiveness scores Overall the mean assertiveness scores prior to the workshop was 68.8 and this improved to 75.5 (p ¼ .0002) following the workshop. There was an improved score noted to 26 of the 28 individual questions between the pre and post-test, with the mean
score for question 19 remaining the same and the mean score for question 16 dropping slightly. When examining the statistically significant changes to individual questions there was a general tendency for the students to report increased level of assertiveness
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pre and post the workshop, however, this change was only statistically significant to questions 2, 5, 8, 17, 21, 24 and 26 (Table 3). Of importance is the significant improvement (p ¼ .008) to question 21 “At work I avoid asking questions for fear of sounding stupid” as well as question 24 (p ¼ .001) “If I was impressed by the actions of a senior colleague, I would tell him/her.” Age We divided the cohort into two age groups one under (n ¼ 23) and the other over (n ¼ 17) 25 years of age (1 student did not give her age and so was excluded from this analysis). There was a statistically significant (p ¼ .005) improvement in mean assertiveness score (from 68.15 to 75.49) in the students who were less than 25. Whilst there was also an improvement in the overall mean score in the group who were older than 25 (from 69 to 73.5) this was not statistically significant (Table 4). There was no difference between perceived areas of strengths and weaknesses in assertiveness with both age groups, having question 15 as their lowest score prior to the workshop and question 9 as the most assertive both before and after the workshop. Discussion There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. This provides encouraging evidence that educational institutions that provide specific and targeted assertiveness education will be rewarded with more assertive graduates. The link between assertiveness and maturity is well understood (Goldman and Olczak, 1981; Twenge, 2001). However, when this was assessed we found a statistically significant improvement in the younger students' scores and whilst there was also an improvement in the overall assertiveness score in the older group this was not statistically significant. As the over 25's did not start with a higher score this may indicate that the older student is more resistant to change. Alternatively the type of training may have better suited the younger students. Whatever the reason it would be important for future research to assess how to better facilitate the needs of older students as they learn this vital skill. When learning assertiveness, some students may have to wrestle with cultural mores and expectations from their family of origin and education (Hijazi et al., 2011). Much of their earlier socialisation may have been based on what others expected that they 'should', 'ought', 'must' do, with some having little opportunity prior to the workshop to develop assertive skills (Hijazi et al., 2011). Unfortunately the numbers of international (mainly Asian and South East Asian) students in the cohort were too small (n ¼ 4) to determine any distinct cultural difference in this groups' assertiveness levels. Further research to determine the effect of an assertiveness training for these students is therefore warranted.
Table 4 Comparison of overall and age related mean level of assertiveness pre and 3 months post assertiveness workshop. Group
Time
Mean score
n
Minimum score
Maximum score
Exact sig. (2-tailed)
Overall score
Pre Post Pre Post Pre Post
68.8 75.5 68.15 75.49 68.8 73.5
39 29 23 17 14 12
53 62 53 62 56 62
92 99 92 99 83.5 86
0.002*
Age less than 25 Age older than 25
0.005* 0.171
755
Howard (2001) noted that improved assertiveness may impact negatively on the students' personal and social lives. With Mc Cabe and Timmins (2003) going so far as to suggest that the students may need to be supported as they learn to deal with such issues. In this study students appeared to find new confidence in the workplace as demonstrated by their significantly improved responses to questions 21 and 24. Many students also reflected their positive evaluation of the workshop on their personal life by making comments such as: “I identified that I need to be more confident and actually know when to step up and express my concerns when necessary without undermining my peer's authority. It was useful for my personal growth” “I believe this training is very useful as it will allow me to better my assertiveness when working in the work place as well as my personal life.” Identified barriers that may prevent nurses from being assertive include lack of knowledge about personal/professional rights, concern about what others will think about their behaviour and anxiety due to a lack of confidence and poor self-esteem (Poroch and McIntosh, 1995). Our study demonstrated an improvement in understanding rights in a group who already seemed to understand these rights (pre score 3.3 to post score 3.6: maximum score 4). We also found a significant improvement in students being prepared to ask questions, even if this was at the expense of “sounding stupid.” It would therefore appear that our students may have overcome some of the barriers to becoming assertive.
Limitations It is recognised that there would be a natural improvement in assertiveness over time, with both life experience and maturity. However, the improvement in the overall perceived assertiveness score in this study occurred over a relatively short period of time (relative to a life-time) and thus most of the improvement can probably be attributed to the specific education on assertiveness the students received. The assertiveness education package was one developed by an individual consultant especially for our students, therefore the study may not be easily replicated in other schools of Nursing and Midwifery, neither are the results necessarily generalizable to other Nursing and Midwifery schools. Those students who did not complete the post-workshop survey could perhaps be assumed to be less assertive than those who chose to remain in the study and if this was the case their nonparticipation could have been responsible for the increase in assertiveness score. However, the mean assertiveness score of those who did not participate in the post workshop survey was actually a little higher (69.18) than the remaining respondents, indicating that if these students had participated the postworkshop score could have been even higher.
Conclusions Assertiveness is an important skill for midwives to develop. Holding these skills enables midwives to advocate for the woman, improves inter-professional communication, and personal confidence. Providing assertiveness training is therefore an important part of any undergraduate midwifery programme. However, dedicated assertiveness training is not always part of higher education and can be costly.
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Although the benefits of teaching this topic have not yet been empirically tested, our pre and post intervention study demonstrates that there are significant and immediate benefits for student midwives, especially in gaining confidence in asking questions and not being afraid to compliment their superiors on a job well done. Whilst our students reported feeling more assertive this may not necessarily translate to changed personal behaviours in the clinical environment. It would be important for future studies to explore this and also if there are any barriers to change that the students experience when they attempt to put assertive skills into practice. Further research is also required to determine more effective methods for enabling older students to improve their assertiveness scores. More research is also needed on whether or not different cultural groups require a different approach when teaching them these skills. Outlining how we approached this particular teaching session may prove to be a useful guide for those involved in teaching assertiveness to undergraduate midwifery students. Overall the students evaluated the workshop as valuable and we found that they self-reported increased assertiveness scores three months following the assertiveness training workshop. Acknowledgements Students undertaking the perinatal mental health course in 2013: for generously agreeing to take part in this research during a very busy year. Maurissa Ailion who designed and delivered the assertiveness training. Prof Adrian Esterman for his assistance with data analysis. References Arslan, E., Akca, K.N., Baser, M., 2013. Levels of assertiveness and peer pressure of nursing students. Int. J. caring Sci. 6 (1), 78e86. Begley, C.M., Glacken, M., 2004. Irish nursing students' changing levels of assertiveness during their pre-registration programme. Nurse Educ. Today 24 (7), 501e510. Deltsidou, A., 2009. Undergraduate nursing students' level of assertiveness in Greece: a questionnaire survey. Nurse Educ. Pract. 9 (5), 322e330. Galassi, J.P., DeLo, J.S., Galassi, M.D., Bastein, S., 1974. The college self-expression scale: a measure of assertiveness. Behav. Ther. 5 (2), 165e171. Gambrill, E.D., Richey, C.A., 1975. An assertion inventory for use in assessments and research. Behav. Ther. 6 (4), 550e561. Garon, M., 2012. Speaking up, being heard: registered nurses' perceptions of workplace communication. J. Nurs. Manag. 20 (3), 361e371.
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