joumal of Advanced Nurstng, 1990,15,337—356

Effecting personal effectiveness: assertiveness training for nurses Jo Slater BSc (Hons) Cert HEd Cert Counselling Dip HEd CMS MITD Deputy Dtstnct Health Promotton Officer, Central Notttnghamshtre Health Authonty, Mansfield

Accepted for publication 3 May 1989

SLATER J (1989) Joumal of Advanced Nursmg 1 5 , 337-356 Effecting personal efiFectiveness: assertiveness training for nurses This paper descnbes a client-centred approach to assertiveness trairung v«th nurses The approach recognizes and utilizes the skills and resources withm a group, through a process of enablmg rather than teaching The group's own knowledge and expenences are shown to be ai least as valid as other academic and research texts which are referred to In personal development terms they are more valid Technique-based courses are thought to have less impact than this approach, clearly rooted m self-awareness and development After lookmg at the history of asserhveness trairung, and ways of defming it, the paper goes on to descnbe the process and content of a programme which is group led Space is also given to considenng why it may be particularly difficult for nurses to act assertively, due to tradition and stereotypes

INTRODUCTION Tradihonally, nurses have been taught to be acquiescent, passive and submissive m their relationships with others at work Behaviour which is now referred to as 'non-assertive' or 'passive' was normally expected of nurses and women in the past (Hutchmgs & Colbum 1979) My own expenence in the health service shows that this expectation is still around today, as is confirmed by many nurses I speak to However, nurses now find themselves m a situation where they not only wish, but are also required by their code of ethics, to act as advocates for their pahents (UKCC 1984) This, coupled with nurses' efforts to establish their professional standmg as 'nurse prachtioners' (Alleway 1987), means that many now find themselves m a dilemma, where tradihonal expectahons of their role conflict with cunent demands I suspect that this dilemma is part of the reason for a recent significant mcrease m the demand for personal effectiveness workshops, from nurses After d e l i n g what is meant by 'personal effechveness' or 'assertiveness' m the context of this artide, I shaU continue with a bnef resume of the history of assertiveness Correspondence }o Slater, 2 Sherwood Rise Nuncargate Kirkby-m-Ashfield, Notts NG17 9AF

training This will be followed by an examination of possible reasons for nurses' apparent lack of assertiveness (Bakdash 1978), and why assertiveness remains a mode of behaviour which is regarded with at best, suspicion, and at worst, antagonism, m the health service The main body of the arhcle will consist of a review of a recent personal effechveness workshop I was involved in, which together with the former, will suggest a basis from which to further develop trairung m this area

DEFINING ASSERTIVENESS Relahonships demand that people constantly make choices which defme both themselves and those they are interacting with (Nelson-Jones 1986) Nelson-Jones suggests that an individual's capacity for assertion is an important part of defining herself m relationships While I accept that constantly making choices affects the way m which I and others see myself, I have difificulty in regarding 'defmmg' and 'asserhng' myself as two distinct, though integrated activities as Nelson-Jones suggests In my view, the two are mterdependent, l e if I am not able to define myself, I will not be able to be assertive and vice versa As such, I 337

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prefer Kjervik & Martinson's (1979) definition of assertiveness, as a pre-requisite for self-esteem That is, it is a quality and behaviour which expresses a belief that each person is important Therefore, each person is important enough to be recognized and acknowledged and have her needs responded to Assertiveness as a quahty and behaviour therefore demands the use of specific interpersonal skills, l e a person giving expression to her nghts, thoughts and feelings m a way which does not degrade, insult or interfere with the reasonable nghts of others I see these definitions of 'asserhveness' as being synonymous with 'personal effectiveness' and therefore use the two terms interchangeably The mam difference between assertiveness and the other two modes of behaviour with which it is usually discussed (le aggressiveness and non-assertiveness) concems the use and/or abuse of basic nghts Assertive behaviour attacks the problem, not another person, so that the reasonable nghts of all mvolved are respected (Dickson 1982) In contrast to this, aggressiveness is defmed as a person 'standing up' for what she wants regardless of the nghts of others mvolved, non-asserhveness means a person allowmg others to treat her thoughts and feelings in whatever way they want to, regjirdless of her own desires (Alberti & Emmons 1974) This IS not to suggest that assertiveness is an ideal form of behaviour There are positive and negative aspects to assertive, aggressive and passive (or non-asserhve) behaviour (Burley 1983) as will be discussed later However, I would advocate mcreased assertiveness amongst nurses, to improve their self-esteem, self-image and consequently their image as nurses I believe that the former cannot occur without the latter Until that happens, nurses may retam an image of being expected to act as 'the handmaidens of doctors' I feel it is important to the body of this study to understand where this image comes from, if personal effechveness programmes are to be used as a means of reducing the frequency of its usage, as I believe they could be

NURSING'S NON-ASSERTIVE IMAGE In this male-dominated soaety, females leam to care for others rather than themselves (Graham 1984) As a result, they have not nurtured their own self-images Thus, many adult women are faced with the mcongruity of bemg expected to perform professionally and autonomously at the same time as fulfilling a traditionally femmine, passive role As over 90% of nurses are female (Holmes 1987) it seems logical that histoncally, the profession has empha338

sized those elements of behaviour generally assoaated with being 'feminine' (l e non-asserhveness and nurtunng) and discouraged those generally associated with bemg 'masculine' (l e aggressiveness and assertiveness) (Dickson 1982) However, I do not wholly agree with Bradley & Edmberg's (1982) assertion that such non-assertive behaviour has been, and IS, universally appreciated and promoted by others A notable exception is the traditional image of a matron or ward sister, who was expected to display authontanan behaviour That is, behaviour which did not necessanly acknowledge, or indeed respect, the nghts, of others This exception apart, the traditional, passive, nurtunng role of nurses seems to be a major reason for the difificulty they expenence in becoming more assertive, although many express a will to do so A basic premise of assertiveness IS respect for self and others, and assummg responsibility for self, but not for others This view of responsibility conflicts with nurses being responsible for areas of work where their actions have a great impact on the lives of others In addition to this, there may be hmes when they have httle authonty in those areas, e g deadmg treatment regimes Nursmg's image of a canng role could therefore be said to be based on anonymity, and a position of secondary stahis (Bush & Kjeryik 1979) I feel that this has not served nursmg, soaety or pahents to advantage This secondary status conflicts with the UKCC's (1984) stated goal of the nurse—patient relationship, that nurses and patients work together to achieve patients' potential for health As this relahonship and its effectiveness is affected by the role expectations and reaprocal behaviours of both the nurse and pahent, and the nurse and other colleagues, it could not achieve optimum effed with other than asserhve modes of behaviour, where the nghts of all concemed are respected In addihon to the traditions of nursmg itself, when leammg asserhve skills, nurses also have to wrestle with their general soaalizahon and education as children Much of that condihonmg was based on what they 'should', 'ought', 'must' and are 'expected' to do, with little attention given to developmg autonomy and deasion making sblls (Dicbon 1982) When children expenence an asserhve response or feelmg, it IS frequently punished or squashed, they leam to lnbbit naturally asserhve behaviour (Neuman 1969) For example, a parent may expect a child to stop mid-sentence or mid-activity to respond to him or her, but is unlii^ly to reaprocate such behaviour, if the child were to exerase similar demands, it would probably be repnmanded for domg so As such, children leam to suppress legitimate urges to 'stand up' for themselves m some way, because the

Effecting personal effectiveness benefits of an assertive act must be weighed agamst the aversive guilt feelmgs eliated by pursumg it This type of behaviour seems to have been perpetuated m nurse trainmg unhl recently, where the nurse leamer could not demand the same nghts or respect as a qualified colleague, and was expected to react on demand It is therefore not surpnsmg that nurses have been slow to come forward for assertiveness trammg, and that it is not the most recently qualified who do so Recently quahfied staff will hopefully have benefitted fi-om the introduction of student-centred leaming It is the qualified staff who have difficulty accepting the different behaviour pattems of contemporary nurse leamers and who have idenhfied their own need for developing similar skills to those which are now inculcated by nurse trainmg (eg active listening, honest, open communicahon, promotmg equality m mterachons with other colleagues) Further, it is the younger of the qualified staff who seem to notice how nurse leamers interact differently with managers to the way they did and also wish to benefit firom this, although this tendency is changing and older members of staff are now also applymg for these workshops — mdudmg nurse managers Beme's theory of transachonal analysis is helpful m developing a dearer understandmg of the nature of relationships in health care (Beme 1968) In particular, explaining the basic elements of ego states and how they affect interpersonal transactions, seems to help staff to understand the dynamics of their relationships with each other For example, the hierarchy m nursing can perpetuate relationships of 'cntical or nurtunng parent-adaphve child', as can the nurse-pahent relahonship Further exammahon and understandmg of this may help change the pattem of relating to a more effechve one Workshop partiapants might be assisted to understand that 'how' and 'what' they communicate both affects and expresses the extent to which they are respecting other people's rights (and their own) by more extensive use of transactional analysis (TA) theory However, as worbhop content is dictated largely by the partiapants, this may not always be appropnate Also, less time would be left for explonng other issues m more depth A positive aspect of this IS that parhcipants and facilitators alike are conhnually faced with practising one area of personal effechveness — that of mabng choices

developmg the social skills of people who had difficulty with interpersonal communicahon The rationale behind such trammg came fi-om behaviour therapy — the mam tenet bemg that arousing assertive responses in individuals would help them to reduce anxious and submissive ones, thereby assistmg them to function and communicate more effechvely As the success of asserhveness training became evident m terms of recipients' mcreased personal effechveness, other groups adopted it as a way of helping individuals cope with feelings of infenonty and inadequacy (Bradley & Edmberg 1982) Hutchmgs & Colbum (1979) suggest that most of these groups were part of the women's movement, who wanted to be able to assert themselves and achieve goals m a non-aggressive way, so reducmg the negative feelmgs mentioned above Asserhveness trammg has now been extended to health service staff, and nurses in particular Artides telling nurses how to test their level of assertiveness and increase it, regularly appear in the nursmg press, for example. Bond's (1988) recent senes of artides in Nursing Times, which gave examples of nurses bemg assertive, non-assertive and aggressive and strategies for usmg different responses to e g cnticism, aggressively expressed views or requests While useful for increasing awareness, and suggesting ways forward, open leaming approaches do have limitations when applied to interpersonal sblls such as assertiveness For example, they do not ensure feedback and discussion on the strategies attempted, unless a nurse is sufifiaently motivated to convene a like-mmded and equally motivated group of colleagues for discussion When queshoned about this, partiapants in a recent workshop stated that they felt they would be unlikely to do this because of other demands and commitments Group asserhveness trammg for nurses has been found to be effective For example, Argyle (1981) reports on Mandermo's study, which showed highly significant differences due to trainmg, between matched pairs of undergraduate female nurses Limitahons of this study are that no attempt was made to assess long-term effects or to validate findings in practice Long-term evaluation is an area which must be explored m the future if the applicahon of personal effechveness hrammg m nursing is to become established as a valuable use of time

HISTORY OF ASSERTIVENESS TRAINING . J .u , .

REVIEW OF A PERSONAL EFFECTIVENESS PROGRAMME

Aswrtiveness trainmg was mihally mtroduced m the late 1960s as a therapeutic tool for people with mental health problems, who were considered passive (Lazanis 1973, Hutchmgs & Colbum 1979) It was seen as a major tool for

While the specific workshop about to be discussed was unique to the group concemed, it contained many feahires similar to those of previous and subsequent programmes I 339

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am aware that this was due as much to the influence exercized by myself and my co-faaiitator, as it was to parhcipants of such programmes having similar issues, problems and themes which they wish to explore The workshops operated over a penod of 3 full days a 2-day block, with a 1-day follow-up This structure was based on previous expenence which showed that parhapants valued the opportunity to apply their leammg and later retum to discuss the progress, pitfalls and difificulhes which they exf)enenced A parhcular advantage of this structure is the remforcement of leammg and support, which participants expenence by returning to the scime group, and which several do not expenence in their work situation On the contrary, one of the common reachons to applymg assertiveness at work which partiapants exf)enenced, is what Bond calls 'the worm has tumed' (Bond 1986) That is, trymg new behaviour pattems at work can cause discomfort amongst colleagues, who prefer to deal with and reinforce those behaviours which are familiar They may also feel resentful about radical change m their colleague This suggests that there may be advantages to holdmg personal effectiveness workshops for teams of staff However, myself and my co-facilitator both feel that open workshops are preferable to those aimed at one unit, as many of the problems partiapants raise concem immediate colleagues Havmg said that, assertiveness trammg workshops have been components of team buildmg programmes, where other elements of trust buildmg, definmg team roles and styles, etc, allow discussion of sensihve issues Two days of assertiveness trairung alone would be less likely to achieve this and could be counter-productive if that was the mam aim In this case, there were 16 partiapants of both sexes, who came from several branches of nursing mdudmg accident and emergency, midwifery, psychiatry and school nursmg There were also a few parhapants from the preventative and therapeutic services such as dietetics and speech therapy The two faalitators were from health promotion (myself) and continuing nurse education This was for two reasons Firstly, to bnng different sblls and expenences to the programme, the second, and perhaps more important, reason is that the two of us enjoy worbng as a team To help people 'switch off' from their usual work situation and to get to know each other, the first day began with a dyadic exerase Pjirticipants were instructed to work with someone they did not know and to find out three things which that person enjoyed and three which they did not enjoy They then had to feedback one of each of those to the main group 340

Several partiapants later stated that this exercize had helped them to relax, as wasri\eintention Another important funchon which it served was to encourage one partiapant to state that she had been 'sent' and did not appreciate bemg told that she 'needed asserhveness training' This was despite efforts to ensure that all partiapants attended voluntarily, wanted to be there, and that both they and their managers had specified how they hoped to benefit from the programme The partiapant concemed elected to stay, and later stated her appreciahon of the relaxed nature and support of the group This madent illustrates the importance of gtvmg the group 'settling m' time at the begmrung of a workshop, and time to adjust to not bemg m their usual role Had this not occurred, I suspect the partiapant concemed would have felt resentful and probably unwiUmg to partiapate A reason that she was able to parhapate as fully as she did, may be because she was encouraged to voice her resentment and dissatisfachon with how she came to be there It may also be partly attnbuted to the facilitators neither achvely persuadmg someone to, nor dissuading them from, staymg Following the dyadic exerase, further 'settling in' and 'gellmg' of the group was faahtated through small groups idenhfymg their 'hopes and wants' and 'anxiehes and don't wants' regardmg the programme, as can be seen m Appendix 1 (As with other exerases m the workshops, the faalitators also participated m this) The hopes/wants expressed by partiapants (Appendix 1) expressed general desires to be more self-aware, and more confident, as well as speafic desires For example, to leam not to feel guilty', 'to enjoy myself, 'to cope with awkward parents' Some of these hopes/wants indicate a desire to develop the four separate and speafic response pattems into which Lazarus (1973) divides asserhve behaviour These are 1 2 3 4

the ability to say 'no' (refuse requests), the ability to ask favoivs and make requests, the ability to express positive and negahve feelings, and the ability to mitiate, contmue and terminate general considerahons

Lazarus (1973) argues that each of these abihhes requires speafic training, smce the degree of transfer from one to another is slight For example, lackmg an ability to say 'no' does not imply an inability m the otho- three response pattems However, I would argue that speafic traimng in each of these areas is not necessanly the key to personal effechveness m commumcatioa

Effecting personal effectiveness The parhapants in this programme showed that much of what they hop«J to gam concemed feelmgs, e g adequacy, relaxation, confidence Programmes such as this one must therefore address feelmgs and assist partiapants m communicatmg them, rather than focusing on speafic techniques For example, in discussion, partiapants identified that their ability to say 'no' and refuse requests, was hampered by feelmg guilty if they did so, or the possibility of rejection from the other person The hopes/wants listed also highlight the 'situahon specificity' of assertiveness which Edmberg refers to (Edmberg et al 1977) That is, while mdividuals may be capable of bemg asserhve m one situahon, they may become aggressive or passive m another Partiapants showed that they could already idenhfy situations where they wanted to be more assertive, such as dealmg with general practitioners, or with violent or abusive dients (Appendix 1) In addition, participants stated clearly that they did not want to be assertive m every situation and that m some work situations immediate assertive responses would be mappropnate For example, if a pahent suffers a cardiac arrest and a doctor yells aggressively to a nurse 'get the arrest trolley', it would be mappropnate to take the time to confront that behaviour immediately, the immediate concem being that the pahent's life is saved Therefore, it was dear from eariy m the first workshop that the context of interaction determines the appropnateness of response The discussion so far, concems approximately one-third of the first day of woricshops It illustrates that workshop participants soon showed that they had much expenence, knowledge and insight to share The facilitators' role was to recognize this and develop the means for the shanng to occur It was certainly not a case of presentmg a catalogue of theones and techniques, although these were explained, where appropnate

'assertiveness' meant to participants This was achieved through bramstorming 'asserhveness' (Appendix 2) after a relaxahon exercise, where the word was repeated and parhapants asked to note in groups, the images, words, etc, which came to mind Several members of the group stated that the exeraze had truly helped them switch off from their work, and the home life they had left that mommg, and to 'key m' to and begin to enjoy the workshop This showed that while the earlier exercizes had achieved this, to some extent, it might have been more appropnate to use a relaxation technique nearer to the begmrung of the day However, there was also a need to be aware that all partiapants did not have the same needs or responses For example, a few members stated that the relaxahon had caused them to feel 'too wound down' and unable to apply themselves The brainstorms of 'assertiveness' show several associations with power, strength and control Again, the parhapants' own ideas and feelmgs reflect academic wnhngs on assertiveness Notably that asserhveness is a component, or level, of power May (quoted in Bakdash 1978) descnbes four levels of power 1 2 3 4

the power to be, self-affirmation, self-assertion, and aggression

Bakdash argues that when a lower level is ineffectual m achieving a person's needs, the person feels powerless and

resorts to a more extreme, destruchve level

The anxiehes expressed by the group seemed to be largely concemed with embarrassment, other people's percephons and 'mabng a fool of yourself After discussion of these, the group contracted to maintain confidentiality about anyone's personal expenences and statements This m itself seemed to reduce the general level of anxiety dramatically, to the extent where people who had stated anxiety about talbng m groups, became quite vocal Similarly, the faalitators felt sufiftciently confident and secure withm the group to inform members that there was no set programme, that a fluid structure to the workshop days was mtended, that at hmes the group may be required to decide 'where to go next'

While assertiveness involves power m the sense of responding to a situation or behaviour effectively, I do not feel it appropnate to view it as more 'extreme' and destruchve than 'self-affirmahon' or 'bemg' This would seem to contradict Maslow's (1968) theory of self-actualization, which states that self-actuahzahon and high level wellness are based on a high degree of self-esteem Assertiveness and self-esteem cannot be placed m a hierarchy, if it is accepted that inaeased self-esteem leads to mcreased assertiveness and vice versa Indeed, assertiveness is an expression of self-esteem While discussmg the items raised by the bramstorm, the group highlighted the importance of a person's pCTcephons of their nghts m any situahon This led to the next session, which explored how the nghts people jjerceive they have afifect their level of assertiverwss The group discussed a need to establish the difference between theu- role nghts and human nghts (Appendix 3),

The process referred to above began immediately with a deasion to 'get into asserhveness' by lookmg at what

and the need for confidence to fulfill these human nghts m any given situahon Confidence m themselves and theu341

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nghts, was both crucial to their abihty to be assertive, and a component of that assertiveness Having formed a list of human nghts and compared this with a sample list compiled firom vanous assertiveness trainmg manuals (Appendix 4), the group established 'choice' as most important Several participants stated that they now felt it assertive to make a decision not to respond with assertive behaviour m some situations For example, as well as being mappropnate in a given situation, one individual said that she sometimes prefened to respond passively, to fulfill her basic nghts of being left alone and treated with respect and dignity This proved useful m helpmg partiapants to establish that, while the workshops were an opportunity to practise assertive sblls, there was neither a demand nor expectation that this should happen at all hmes The group's chart of the link between human nghts and confidence reflects elements of Bond's (1986) theory of a cycle of stress and confidence Stress can result m lower self-confidence or mabng assertiveness more difificult In tum, non-assertiveness may lead to inaeased stress due to personal needs not bemg met, and so the cyde goes on Bond suggests that breabng this cyde can transform it mto a posihve one This is achieved, because the break occurs when an individual recognizes the rights she has m communication with others and the nghts they have Again, by doing this, the group had shown that they had the resources amongst themselves, to identify and maease their asserhveness, and did not require academic mput to provide them with the necessary mformation This group more than any other I have worked with, convinced me of the value of 'facilitatmg' rather than 'teaching', and the effechveness of that approach For example, the fact that the group dictated much of their own programme and came up with ideas and 'answers' which reflect academic wntmgs, had a posihve effect on the esteem of the group as a whole A significant factor m fulfillmg human nghts which this group raised, but to which academic wntings pay little attention, is the affect of assumphons and irrational bebefs on behaviour Firstly, parhapants gave the same argument as Kjervik (1979), that while most jjeople profess to believe that all people are aeated equal, certain ones are assumed on the

These examples indicate factors which seems to have a strong beanng on an mdividual's ability to be assertive, firstly, their role nghts m a given situation, and secondly, any irratioruJ beliefs they hold The first issue, role nghts, is one which few texts on assertiveness address Where they do, references to the influence of role nghts on human nghts is given little attenhon The role nghts of nurses are affected by the difference m assumed role nghts, of males and females referred to earlier, nursmg bemg a largely female profession From discussions with this group, it seems that in health care the male-female role has taken on the cancature of a game (m the transachonal analysis sense) Nurses may sometimes respond to the male ego as somethmg which needs protection, by not winning, not bemg 'too' smart, not being 'too' successful and not receiving 'too' much attenhon As such, they may negate their jjersonhood, uniqueness, strength, self-worth and basic human nghts This seems to apply equally to nurses of both sexes Also, it IS an accepted fact that male nurses are more likely to be promoted to the chief management posts in nursing (Holmes 1987) It might therefore be assumed that they are more practised m exerasmg their nghts (both role and human) and that it is more acceptable for them to do so In view of this I suggest that female nurses may expenence more dtfificulty m havmg new assertive behaviour accepted by theu- peers, than might their male colleagues Having explored issues of human nghts and role nghts, the group went on to establish what they saw as the components of an assertive situahon This was seen as a 'thmbng through strategy', which combmed the nohon of respectmg human nghts with that of respondmg to a particular behaviour, rather than a person as a whole, as follows Components of assertive situation 1 2 3

basis of education, age, sex, race, etc, to have more nghts than others Several participants referred to mequality withm the health servtce, as well as the inequality between men and women (Webb 1981) In parhcular, they referred to the unequal nghts held by, for example, nurses, compared with doctors, students with qualified staff, and prachtioners with managers, and m many instances, staff with pahents 342

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The person's basic human nghts What nghts do I have m this situation What IS the speafic behaviour to which I am respondmg? My reaction to that behaviour How do I react — what do I do! How do I feel about it? What do I think? What behaviour would I prefer to see m the person I am dealmg with? What are the positive and negahve consequences for that person if they display the behaviour I want them to? Potential consequences of an assertive response — what'll happen if I make an asserhve response?

Effecting personal effectiveness The 'thinking strategy' above, leads an individual to acknowledge any irrational behefs (point three), so providing an opportunity to refute them Gerrard et al (1980) cite three basic lrrahonal beliefs, held by most people 1 2 3

1 being confVontive, 2 saying no and refusing requests, 3 mabng requests, If others don't like me it's awful —fear of rejection 4 expressing opinions, If I'm not perfect, it's temble—fear of imperfection m 5 engaging m and maintaining conversation, and self 6 shanng experiences and feelings If others make mistakes they're bad and deserve to be punished by me — intolerance of imperfection in others Second workshop

These irrational beliefs can be a major block in using assertive skills (Gerrard et al 1980) As with role nghts, there seem to be beliefs which nurses hold because of their role Some of the ones identified by the group include 1 2 3 4 5

It's uncanng to be assertive When something goes wrong someone must be to blame Doctor's word is gospel, I can't suggest altematives I must not show feelings Everyone should like and approve of me

As well as including the three irrational beliefs given above, the group also communicated many of those stated by Bond (1986) as irrahonal beliefs which nurses hold These hinder their ability to be asserhve Usmg its own resources the group has again ldenhfied a fundamental element of being personally effechve — recognizing and refutmg liTahonal beliefs So far, the worbhop had concentrated on 'selfawareness' rather than specific techniques or skills for use when mterading with others It was decided at this point to move into skills development for the last part of the first day The group concentrated on verbal skills at this stage The last session of the day before 'rounding-up' concentrated on the following skills 1 2

assertiveness skills listed by Gerrard et al (1980), not one of them The other sblls being

Adive listening, using open queshons as tnggers for the person talking Giving and receiving feedback

The format for this exeraze consisted of groups of three, with partiapants alternately taking the roles of 'listener', talker' and 'observer' Non-verbal communicahon was touched on at this point, with observers giving feedback about it However, the main focus of the exerase remained the use of discreet assertive verbal skills Several parhapants said how valuable this particular sechon of the programme was to them, in terms of providing a basis on which to build specific assertion skills such as saying no' I would argue that achve listening, and giving and receiving feedback, are the basts for all the other verbal

The second workshop of the programme concentrated on the following elements of personal effectiveness 1 2 3

non-verbal communication, self-image and feedback from others about the image presented, and identifying the situational specificity, of specific elements of asserhveness

Having used an Assertive Response Discrimination Index as a means of reviewing the previous day, the group moved on to examining the effect of non-verbal communication on behaviour To do this, they were asked to close their eyes and to imagine that they were a passive person Partiapants were then instructed to move around the room m this passive manner using only non-verbal communication This was repeated for aggressive and assertive behaviour, with plenary feedback, after each behaviour typ)e had been expenenced The group's feedback after each section (Appendix 5) illustrates Henley's (1977) argument that non-verbal communication not only reflects emotion but also reshmulates it For example, the feedback regarding submissive or passive behaviour shows how tabng this on engendered negative self-image and reduced self-confidence in parhapants The feedback on aggressive non-verbal behaviour illustrates the strength of feeling withm the group It shows the extent to which non-verbal communication affects both thought processes and feelings Also, the argument that assertiveness and self-esteem are mextncably linked is supported by the feedback from the group An important piece of leaming at this point was how

safe everyone felt when people were acting asserhvely This illustrates that feeling secure can be an important element of successful asserhve behaviour The strength of non-verbal communication as the deadmg factor in the success or failure of assertiveness was thus estabhshed Regarding the situational speaficity of assertiveness, many partiapants communicated that elements of assertiveness gave them difficulty in different situahons, rather 343

J Slater than assertiveness as a whole, as Hutchmgs & Colbum (1979) suggest To explore this further, the group used an assertion self-assessment table (Appendix 6) A table of responses for the whole group (Appendix 7) was valuable for identifying simileafiaty' as well as 'people' or situahon specifiaty' Further, I am convinced that allowing a group to move at their own pace, to define, explore and pradise discreet elements of assertiveness, is more useful than presenting a set of techruques such as 'broken-record' or 'persistency' (for example, Bolton 1979, Herman 1978, Townend 1985, Smith 1975) Such techruques are urJikely to be useful unless people are aware of both what hinders their assertiveness, and how they can adapt techruques for their own use The main section of this second workshop in the programme concemed the difference or congruence between self-image and the image presented To help partiapants find out how they came across to one another, a 'carousel' was used, that is, inner and outer cirdes of people, giving each other feedback on their behaviour and how they present to and are perceived by others This proved to be a useful expenence for everyone m the group Some people were surpnsed at how positively they came across to others, while others learnt some negative (m their minds) aspects which they portrayed The image exerase illustrated the importance of feedback as part of a process of effedive leaming and development It also required nsk tabng for many parhapants If nursing is to develop as a profession m its own nght, it seems essenhal, as Kjervik (1979) advises, that nurses take the nsk of elevating their self-images and recogruzmg theniselves as people with valuable knowledge and experhse The 'carousel' seemed to begm the facilitation of that process for rrumy partiapants 344

At the end of the second workshop, partiapants deaded that they wanted to use the follow-up day to look at handling 'conflict', 'anger' and 'cntiasm' They also agreed to review a situahon where they felt they had been asserhve, and one where they had been non-asserhve or aggressive (but would have liked to have been assertive), for the first session of the follow-up workshop

FOLLOW-UP WORKSHOP On reviewing expenences since the first 2 days of the programme, it again became clear that some of the mam blocks to using assertive behaviour were the situahon and other people involved, and the irrational beliefs which went along with this It was also evident that many members of the group felt pleased with their efforts to speak for themselves and use 'I' statements This in itself appeared to be a major step forward m becoming more personally effechve in difficult situahons Owning feelings and behaviours seemed to increase participants' confidence to continue in an assertive mode Initially, the task of finding a way of faahtatmg the explorahon of anger, conflict and cnhcism proved difficult for the two faalitators, partly because the group wanted to explore all three' However, after much discussion, a scheme was devised which proved to be successful on the day A guided fantasy exeraze about emohons formed the basis of this scheme, with partiapants remembermg previous expenences which involved cnhasm, anger and conflid, then shanng their feelings The fantasy evidently rebndled very strong emohons for some participants, parhcularly in the expenences of cntiasm and anger. For example, some cned, others had denched fists, some were curled in a foetal posihon, while others took up a lot of space m companson The responses of 10 partiapants (Appendix 8) show that in general the cnticism and anger fantasies brought greater awareness of physical, mental and emotional reactions This was confirmed in discussion with the group, when many partiapants stated that they felt much more able to cope with their feehngs in the corrflict fantasy It was also stated how valuable the shanng of these fantasies was (as a means of copmg with emohons which had not previously been acknowledged) before discussmg possible asserhve responses to a similar event Followmg the shanng of expenences, partiapants deaded to work in small groups on one of the three areas, m nwre depth They discussed what 'conflict', 'anger' or 'cnhasm' meant to them, then proceeded to examine strategies for dealing with it more effedively in future Some of their work can be seen m Appendix 9

Effecting personal effectiveness

As has been said about most of the exerazes ated previously, the group had the necessary resources amongst themselves to meet their needs, with the help of facihtators, lllustrahng that the dient will take the praditioner where she/he needs to go (as m Rogenan Counselling) The fantasy exercise above all others in the programme showed how important self-awareness is as the basis for self-development, particularly in terms of personal effechveness

FEEDBACK FROM THE GROUP

completed this programme In view of this I feel confident that personal effechveness programmes can make a contnbution (albeit small) to a changing organization culture Three statements made by partiapants at the end of the programme discussed above, seem the most appropnate way of concluding this article 1 2 3

Role nghts usually ovemde human nghts m a work situation There is always a choice You can alter your response, but not that of others

The feedback from the group, 3 weeks after the last workshop (Appendix 10) showed that each person leamt and gained very different things from the programme This reinforces the argument that personal effectiveness programmes are more likely to be effechve and beneficial if they are based on responding to the needs of parhapants, rather than on a set agenda, or putting participants 'through the hoops' of a senes of exercizes which could be meaningless to them

My thanks to Barbara, Kathy, Helen, Jean, Sue, Penny, Sherry, Bnan, Ann, Chns, Margaret, Glenys, Garry, Joan, Sarah and Wendy, who partiapated in the Personal Effechveness Programme referred to herein and gave their f)ermission for records of their work to be used, also to David, with whom I co-facilitated the programme, and Joan Hopbnson and Diana Betts for secretanal support

CONCLUSION

References

The development of self-awareness is crucial to the development of assertiveness, which nurses and all other health care workers have a nght to pursue They have the nght to utilize those behaviours which are honest, direct and selfenhancing They also have the nght to acknowledge their feelings and to not feel guilty about respondmg to others, in a way which does not correspond with the traditional image of a nurse While there are no guarantees for obtaining what is wanted or needed as a result of being assertive, the probability IS enhanced because of greater personal awareness and so greater clanty about a way to proceed I recognize that helping staff to become more self-aware and thereby more personally effechve will not radically alter their worbng or social environment Further I accept that assertiveness training programmes put the onus for change upon individuals rather than the organization as a whole However, I cannot agree with Henley that focusing on individuals conshtutes 'the most vicious sort of blaming the victim' (Henley 1977) I believe that expenences in programmes such as this can be used to assist the aeation of condihons where people can assert themselves These condihons (as m the workshops discussed) include openness, trust, constructive feedback and, I think of pnmary importance, a high degree of flexibility The foundahons for such conditions are noticeable in units where several members of staff have

Alberti R C & Emmons M L (1974) Your Perfect Right A Guide to Assertive Behavtour Impact, California Alleway L (1987) Make or break? Project 2000 an outside perspective Nurstng Ttmes 83(18), 25-26 ArgyleM (1981) Soaal Skills and Health Methuen, London Bakdash D P (1978) 'Becoming an assertive nurse' Amencan Journal of Nursing October, 1710-1712 Beme E (1968) Games People Play— The Psychology of Human Relationships Penguin, Harmondsworth Bolton E (1979) People Skills How to Assert Yourself Listen to Others and Resolve Conflicts Prentice-Hall, Englewood Cliffs, New Jersey Bond M (1986) Stress and Self Awareness A Guide for Nurses Heineman, London Bond M (1988) 'Assertiveness Training' Senes of artides m Nursing Ttmes 84(9) to 84(16) Bradley JC & Edmberg M A (1982) Communication in the Nursing Context Appleton-Century-Crofts, New York Burley A M (1983) Managing Asserttvely Wiley, New York. Bush M A &KjervikD (1979) The Nurse's Self Image In Women m Stress A Nursing Perspective (Kjervik D K & Martmson I M eds), Appleton-Century-Crofts, New York Dickson A (1982) A Woman in Your Own Right Quartet, London Edinberg M A , Karoly P & Gleser G C (1977) Assessing assertion m the elderly Journal of Clinical Psychology 33, 869-874 Gerrard B A , Boniface W J & Love B H (1980) Interpersonal Skills for Health Professionals Reston Publishing, Reston.

Acknowledgements

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Graham H (1984) Women, Health and the Family Wheatsheaf, London Henley N M (1977) Body Politics Power, Sex and Non-Verbal Communication Prentice-Hadl, Englewood Cliffs, New Jersey Herman SJ (1978) Becoming Assertive A Guide for Nurses Van Nostrand, New York Holmes P (1987) Man appeal Nursmg Times 20(83), 24-27 Hutchmgs H & Colbum L (1979) An asserhveness training programme for nurses Nursmg Outlook 27, 394-397 K)ervik D K & Martinson I M (1979) Women in Stress A Nursmg Perspective Appleton-Century-Crofts, New York Lazarus A A (1973) On assertive behaviour a bnef note Behaviour Therapy 4, 697-699 Maslow A (1968) Toward a Psychology of Bemg Van Nostrand, New York pp 3-8

Nelson-Jones R (1986) Human Relationship Skills Training and Self Help Cassell, London Neuman D (1969) Using assertiveness trairung In Behavioural Counsellmg (Knimboltz J D & Thoresen CE eds). Holt, Rinehart and Winston, New York Smith M J (1975) When I Say No I Feel Guilty Bantam Books, New York TownendA (1985) Assertion Training Crown, London UKCC (1984) Code of Professional Conduct for Nurses, Midwives and Health Visitors, 2nd edn United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London Webb C (1981) The men wear the trousers Nursing Mirror

154(2), 29-31

APPENDICES APPENDIX 1 HOPES/WANTS AND ANXIETIES/DON'T WANTS Hopes

Anxieties

To enjoy myself To become more assertive Recognize Raws m own character To be more confident when speabng to strangers To be able to use what things we have gamed from the course in everyday situations To be more effective when dealing with people problems Aggression — cojje with' Recogruze others' nghts Define needs Confidence To be more assertive when tutonng Better manager Greater awareness To leam how to say 'No' and shck to it Benefit from others' expenences To leam not to feel guilty Reasons for others' behaviour To leam to say 'No' To feel relaxed To be able to deal with GP To overcome shyness when meeting new people To control spontaneous answers Think before you speak To cope with awkward parents To deal with violent and abusive clients To feel more adequate when managing stafif

Public speaking Revealing yourself Making a fool of yourself What the Boss will ask when 1 get back to work I don't want to become over-assertive We all hate role-play Embarrassment Group-work Role-play Talking m front of groups Vulnerability Relating expenences Recognizing shortcomings (to leam how to say 'No' and shck to It) Embarrassment Inadequacy Self-revelation Will be exhausted at end of day Give people the wrong impression Forget people's names Being made to look a fool Being ribbed Role-play General outcome Why me? Confidentiality I make a pratt of myself and no one supports me

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Effecting personal effectiveness

That we get mixed up about what's what and who's doing what That we don't leam anything I don't follow what's happening in the group

Hopes Get support from everyone, especially when 1 get it wrong To enjoy it I don't talk too much 1 don't talk double dutch I hope I leam something from the group

I hope there's a sense of humour I hope I remain open with everyone Confidentiality Participates — everyone I hope everyone speaks for themselves only 'Y statements When someone speaks — others listen Share feelings Being able to handle difficult situations and people better To relate to peer groups better To realize that other people are in the same situation

APPENDIX 2 ASSERTIVENESS BRAINSTORMS (POST RELAXATION, FOUR GROUPS) •STRENGTH FORTITUDE POSITIVE RELATIONSHIP — 'CARTOON COMPLAINTS BODY LANGUAGE WORKING RELATIONSHIP CLASSROOM MANAGEMENT EFFECTIVE COMMUNICATION

•DOMINATION POWER PEACE CALM CONFIDENCE ? Is it important SELF-CONTROL BOSSINESS

'confidence aggression images — (1) aggressive colleague (2) Mrs Thatcher unfeminine powerful strong strong-willed what I want to be effectiveness work other people s opinions — important •don't let them put one over on you tolerance be stronger self-control' strength efiFective communication posihve approach

347

J Slater APPENDIX 3 GROUP FLOWCHART HUMAN RIGHTS 1

Human nghts everyone of us possess — have a nght to exf>ect it from others NEED TO ESTABUSH Role > Human nghts Rights •«—

2

Confidence — to fulfill my human nghts

APPENDIX 4 HUMAN RIGHTS AS LISTED BY GROUP To choose To be yourself To have own opinions To question To 'feel' To enjoy To be true to own pnnaples To say no/yes

To change your mind To make mistakes To respect the nghts of others To respect yourself To be responsible for own actions To ask things of others To be resp>ected by others

Sample list of basic human nghts

The nght to do anything as long as it does not violate the rights of someone else The nght to maintain your dignity by being properly assertive — even if the other person feels hurt — as long as you do not violate the other person's basic human nghts The nght to be independent The right to be successful The nght to have nghts and stand up for them The nght to be left alone The nght to be treated with respect and dignity The nght to be listened to and taken senously The right to get what you pay for The nght to initiate a discussion of the problem with the person involved and so danfy it m borderhne interpersonal cases where the nghts mvolved are not dear

The right to have and express your own feelings and opinions To nght to refuse requests without having to feel guilty or selfish The right to consider your own needs The right to set your own priorities and make your own decisions The nght to change The nght to deade what to do with your own property, body and time The nght to make mistakes — and be responsible for them The nght to ask for what you want (realizing that the other person has the nght to say no) The nght to ask for information (mdudmg from professionals) The nght to choose not to assert yourself

348

Effecting personal effedtveness APPENDIX 5 GROUPS RESPONSES TO NON-VERBAL BEHAVIOUR EXERCISE

Submissive/passive Heavy Depressed Withdrawn Wish to be alone Empty Vulnerable Angry ShufHing feet Downward arm movement Facial expression — clenched teeth No eye contact Feeling of being walked over Anything for a quiet life Closed' Defeat Tense Useless Nervous Worthless Feel 'used' Revengeful Frustrated Sluggish/slow Pathehc Inadequate

Aggressive Determined Tough Ruthless Dominating 1 know it all I'm gonna get 'em 1 am nght I don't give a damn what other people say Self-importance Big Stiff Hard Occupying space Strutting around Snortmg Purposeful Frustration at controlling it I'll get you for that

Clenched fists Jaw well set — jutting forward Finger wagging Aggressive stance Would rather avoid it Enjoyed it being somebody else I know I'm going to win Felt more comfortable Feel guilty afterwards More enjoyable than submissive Easier to meet aggression with aggression

Assertive Win-win Balanced Good Confident 'Strong' Well-being Free flowing movement Self-esteem I've made the nght deasion In control Relaxed Peaceful Comfortable Enjoyable Happy Satisfachon At ease Easy Taller I like people I like me Having regard for other people All together Not avoiding Not competition Eye contact Open posture Loose/purposeful Appropnate Equabty Bonhomie

349

Slater

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