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Transcript of Assertiveness Training in Midwives
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 15
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
Article historyAccepted 23 September 2014
Keywords
Assertiveness
Undergraduate education
Midwifery
a b s t r a c t
Assertiveness can be de1047297ned as an interpersonal behaviour that promotes the fact all people in a rela-
tionship 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 assertive-
ness 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 frac14 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 1047297ndings provide encouraging evidence that educational institutions that offer speci1047297c andtargeted assertiveness education will be rewarded with more assertive graduates
copy 2014 Elsevier Ltd All rights reserved
Background
Assertiveness can be de1047297ned 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 be-
tween 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
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 Asser-
tiveness 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 fewstudies exploring the bene1047297ts of assertive
behaviour for nurses (Kilkus 1993 Lawton Stewart 2005 Sudha
2005) however this is less well explored in the midwifery profes-
sion One of the core competencies of a registered midwife is to act
as an advocate to protect the rights of woman in relation to ma-
ternity care (NMBA 2006) This involves acknowledging and
respecting the womans 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 midwifes
role At times this will include facilitating interactions that require
skilful negotiation and assertiveness It is not uncommon to 1047297nd
midwives dealing with highly aroused partners andor 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
Corresponding author School of Nursing and Midwifery Division of Health
Sciences University of South Australia Adelaide 5001 Australia Tel thorn61 08
83021161 fax thorn61 08 83022168
E-mail address janewarlandunisaeduau (J Warland)
Contents lists available at ScienceDirect
Nurse Education in Practice
j o u r n a l h o m e p a g e w w w e l s e v i e r c o m n e p r
httpdxdoiorg101016jnepr201409006
1471-5953copy 2014 Elsevier Ltd All rights reserved
Nurse Education in Practice 14 (2014) 752e756
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 25
midwiferystudents 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 pro-fessional and autonomous These factors may act to reduce a mid-
wifes 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 speci1047297c 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 neces-
sarily innate and therefore may be learned (Arslan et al 2013
Kilpatrick Forchuk 1992 Lee Crockett 1994 Lin et al 2004)
This paper exploresone 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 identi1047297ed
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 specif-
ically created for use with Irish undergraduate nursing students
We adapted it for use with undergraduate midwifery students by
changing the word ldquopatientrdquo to ldquowomanrdquo The questionnaire
included 28 4 point Likert questions with the options lsquoalwaysrsquo
lsquooftenrsquo lsquorarelyrsquo and lsquoneverrsquo The questions were designed to deter-
mine students current level of assertiveness both in the workplace
and in social settings and had been validated both by the de-
velopers (Begleyamp Glacken 2004) and through a similar study to
ours (Deltsidou 2009) In addition to the assertiveness question-
naire students were also asked their age range and enrolment
status (ie domestic or international)
Approach
The study was designed to measure midwifery students asser-
tiveness immediately prior to the start of the one-day assertivenesstraining 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 1047297rst
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
individuals assertive beliefs and behaviours which can help theindividual change how they view themselves and establish self-
con1047297dence and reduce social anxiety (Lin et al 2008) The
workshop was run by the Principal Consultant of a local Counsel-
ling and Consultancy Service She holds quali1047297cations 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
De1047297nition of assertiveness
Overcoming dif 1047297culties in becoming assertive
Steps in giving assertive criticism
The role of emotional intelligence stress fear control power
respect self-con1047297dence 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 in1047298uence of positional power on ones ability to assert
oneself
what can in1047298uence peoples views of assertive communication
discussion of a coroners report (Lock 2012) in which the mid-
wives 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 eval-
uation survey There was greater than 98 broad agreement
(Strongly agreeAgree) 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 ldquodirect entryrdquo students ldquoregistered nursesrdquo under-
taking our undergraduate midwifery program receive ldquocreditrdquo 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 frac14 41 ()
Age group
19e24 years 23 (56)
25e30 years 6 (15)
31e36 years 3 (7)
37e42 years 5 (12)
gt43 years 2 (5)
Missing 2 (5)
Enrolment status
International student 4 (10)
Domestic student 34(83)Missing 3 (7)
All were female
J Warland et al Nurse Education in Practice 14 (2014) 752e756 753
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 35
Ethical considerations
Ethics approval was gained from the Universitys 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 theirparticipation or non-participation The assertiveness training
workshop was not linked in any way with unit assessment
Data analysis
The assertiveness lsquoscorersquo 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
ldquoalwaysrdquo 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 assertivenessscores 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 688
(range 53e92) (Table 3) The lowest mean score was to question 15
(I am careful to avoid hurting other peoples feelings) The highest
mean score for all questions was to question 3 (I 1047297nd it dif 1047297cult 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 dif 1047297cult
Post workshop assertiveness scores
Following the workshop the mean assertiveness score was 755
(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 ldquoneverrdquo to this reverse scored question
Overall assertiveness scores
Overall the mean assertiveness scores prior to the workshop
was 688 and this improved to 755 ( p frac14 0002) following theworkshop There was an improved score noted to 26 of the 28 in-
dividual 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 statisticallysigni1047297cant changes to individual questions there was a general
tendency for the students to report increased level of assertiveness
Table 2
Workshop participation evaluation data
Question 5 (High) 4 3 2 1 (low) Total
Subject matter 34 7 41
Interest level 22 18 1 41
Objectives 28 13 41Presentation 31 8 2 41
Learning value 23 17 1 41
Participant involvement 29 10 2 41
Table 3
Assertiveness scores
Question Time Average
score
Exact sig
(2 tailed)
1 At work I tend to keep my
feelings to myself
Pre 21 0225
Post 232 I feel uncomfortable asking
a colleague to do a favour
for me
Pre 24 0011
Post 28
3 I 1047297nd it dif 1047297cult to compliment
and praise friends and
acquaintances
Pre 35 0393
Post 36
4 If a senior colleague made an
unreasonable request I
would refuse
Pre 26 0067
Post 29
5 I enjoy starting conversations
with acquaintances and
strangers
Pre 25 0009
Post 295
6 I 1047297nd criticism from friends and
acquaintances hard to take
Pre 24 0276
Post 26
7 I want to know what my rights
are in the work place
Pre 33 0053
Post 36
8 If a friend makes an unreasonable
request I would 1047297nd it dif 1047297cult
to refuse
Pre 25 0039
Post 29
9 I would feel uncomfortable paying
a compliment to a junior colleague
Pre 35 0248
Post 37
10 If I was busy I would ignore the
demands of a senior colleague
Pre 16 0730
Post 165
11 When I know a friends opinion
is wrong I would disagree with
himher
Pre 275 0193
Post 295
12 At work I feel unsure what to say
when I am praised
Pre 25 0234
Post 27
13 I tend to be over-apologetic to
friends and acquaintances
Pre 21 0385
Post 23
14 I try to avoid con1047298ict at work Pre 16 0262
Post 18
15 I am very careful to avoid
hurting other peoples feelings
Pre 15 0256
Post 16
16 In a group I make the decisions Pre 27 0506Post 25
17 I would ask for constructive
criticism about my work
Pre 27 0019
Post 30
18 When I am with friends I am
frank and honest about my
feelings
Pre 31 0282
Post 33
19 If a colleague upsets a woman
(client) I would challenge
himher about it
Pre 25 0978
Post 25
20 If I disagreed with a decision made
by a senior colleague I would tell
himher
Pre 22 0328
Post 24
21 At work I avoid asking questions for
fear of sounding stupid
Pre 26 0008
Post 30
22 I feel uncomfortable asking friends to
do favours for me
Pre 265 0145
Post 29
23 When someone pays me a complimentI feel unsure of what to say Pre 25 0346Post 27
24 If I was impressed by the actions of a
senior colleague I would tell himher
Pre 28 0001
Post 34
25 I tend to be over-apologetic to
colleagues
Pre 21 0487
Post 22
26 I tend to be over-concerned about my
womans (client) welfare
Pre 195 0029
Post 23
27 I would feel uncomfortable expressing
annoyance at a senior colleague
Pre 18 0280
Post 20
28 I am a follower rather than a leader Pre 245 0270
Post 26
Bold text is reversed scored
J Warland et al Nurse Education in Practice 14 (2014) 752e756 754
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 45
pre and post the workshop however this change was only statis-
tically signi1047297cant to questions 2 5 8 17 21 24 and 26 (Table 3)
Of importance is the signi1047297cant improvement ( p frac14 008) to
question 21 ldquoAt work I avoid asking questions for fear of sounding
stupidrdquo as well as question 24 ( p frac14 001) ldquoIf I was impressed by the
actions of a senior colleague I would tell himherrdquo
Age
We divided the cohort into two age groups one under (n frac14 23)
and the other over (n frac14 17) 25 years of age (1 student did not give
her age and so was excluded from this analysis) There was a sta-
tistically signi1047297cant ( p frac14 005) improvement in mean assertiveness
score (from 6815 to 7549) 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 735) this was not
statistically signi1047297cant (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 andafter the workshop
Discussion
There was an overall improvement in self-perceived assertive-
ness scores following the assertiveness training workshop This
provides encouraging evidence that educational institutions that
provide speci1047297c 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 signi1047297cant improvement in
the younger students scores and whilst there was also an
improvement in the overall assertiveness score in the older groupthis was not statistically signi1047297cant As the over 25s 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 oppor-
tunity 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 frac14 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
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 1047297nd new con1047297dence in the work-
place as demonstrated by their signi1047297cantly improved responses toquestions 21 and 24 Many students also re1047298ected their positive
evaluation of the workshop on their personal life by making com-
ments such as
ldquo I identi 1047297ed that I need to be more con 1047297dent and actually know
when to step up and express my concerns when necessary without
undermining my peers authority It was useful for my personal
growthrdquo
ldquo 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 per-
sonal liferdquo
Identi1047297ed barriers that may prevent nurses from being assertive
include lack of knowledge about personalprofessional rightsconcern about what others will think about their behaviour and
anxiety due to a lack of con1047297dence and poor self-esteem (Poroch
and McIntosh 1995) Our study demonstrated an improvement in
understanding rights in a groupwho already seemedto understand
these rights (pre score 33 to post score 36 maximum score 4) We
also found a signi1047297cant improvement in students being prepared to
ask questions even if this was at the expense of ldquosounding stupidrdquo
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 inassertiveness 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 speci1047297c 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-workshopsurvey
could perhaps be assumed to be less assertive than those who
chose to remain in the study and if this was the case their non-
participation 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 (6918) than the remaining respondents
indicating that if these students had participated the post-
workshop 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 con1047297-
dence Providing assertiveness training is therefore an important
part of any undergraduate midwifery programme However dedi-cated assertiveness training is not always part of higher education
and can be costly
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 688 39 53 92 0002
Post 755 29 62 99
Age less than 25 Pre 6815 2 3 53 92 0005
Post 7549 17 62 99Age older than 25 Pre 688 14 56 835 0171
Post 735 12 62 86
J Warland et al Nurse Education in Practice 14 (2014) 752e756 755
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 55
Although the bene1047297ts of teaching this topic have not yet been
empirically tested our pre and post intervention study demon-
strates that there are signi1047297cant and immediate bene1047297ts for student
midwives especially in gaining con1047297dence in asking questions and
not being afraid to compliment their superiors on a job well done
Whilst our students reported feeling more assertive this maynot 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 KN Baser M 2013 Levels of assertiveness and peer pressure of
nursing students Int J caring Sci 6 (1) 78e
86Begley CM Glacken M 2004 Irish nursing students changing levels of asser-
tiveness during their pre-registration programme Nurse Educ Today 24 (7)501e510
Deltsidou A 2009 Undergraduate nursing students level of assertiveness inGreece a questionnaire survey Nurse Educ Pract 9 (5) 322e330
Galassi JP DeLo JS Galassi MD Bastein S 1974 The college self-expressionscale a measure of assertiveness Behav Ther 5 (2) 165e171
Gambrill ED Richey CA 1975 An assertion inventory for use in assessments andresearch 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 andassertiveness in males and females J Youth Adolesc 10 (1) 33e44
Hijazi A Tavakoli S Slavin-Spenny O Lumley M 2011 Targeting interventionsmoderators of the effects of expressive writing and assertiveness training onthe adjustment of international University students Int J Adv Couns 33 (2)101e112
Howard D 2001 Student nurses experiences of project 200 0 Nurs Stand 15 (48)
33e
38Kilkus SP 1993 Assertiveness among professional nurses J Adv Nurs 18 (8)
1324e1330Kilpatrick H Forchuk C 1992 Assertiveness training does it make a difference
J Nurs Staff Dev 8 (2) 60e65Laschinger HKS Leiter M Day A Gilin D 2009 Workplace empowerment
incivility and burnout impact on staff nurse recruitment and retention out-comes J Nurs Manag 17 (3) 302e311
Lawton S Stewart F 2005 Assertiveness making yourself heard in districtnursing Br J Community Nurs 10 (6) 281e283
Lee S Crockett MS 1994 Effect of assertiveness training on levels of stress andassertiveness experienced by nurses in Taiwan Republic of China Issues MentHealth Nurs 15 (4) 419e432
Lin Y-R Shiah I-S Chang Y-C Lai T-J Wang K-Y Chou K-R 2004 Evaluationof assertiveness training program on nursing and medical students assertive-ness self esteem and interpersonal communication satisfaction Nurse EducToday 24 (8) 656e665
Lin Y-R Wu M-H Yang C-I Chen T-H Hsu C-C Chang Y-C Tzeng W-CChou Y-H Chou K-R 2008 Evaluation of assertiveness training for psychi-atric patients J Clin Nurs 17 (21) 2875
e2883
Lock J 2012 Inquest into the Death of Preston Paudel Coroners Court Toowoombaand Brisbane Retrieved 26th March 2014 httpwwwcourtsqldgovau__dataassetspdf_1047297le0005165470cif-paudel-p-20121025pdf
Lounsbury JW Loveland JM Sundstrom ED Gibson LW Drost AWHamrick FL 2003 An investigation of personality traits in relation to careersatisfaction J Career Assess 11 (3) 287e307
Mc Cabe C Timmins F 2003 Teaching assertiveness to undergraduate nursingstudents Nurse Educ Pract 3 (1) 30e42
McCartan PJ Hargie ODW 2004 Assertiveness and caring are they compatible J Clin Nurs 13 (6) 707e713
NMBA 2006 National Competency Standards for the Midwife Nursing andMidwifery Board of Australia Retrieved 26th March 2014 httpwwwnursingmidwiferyboardgovau
Poroch D McIntosh W 1995 Barriers to assertive skills in nurses Aust N Z JMent Health Nurs 4 (3) 113e123
Rathus SA 1973 A 30-item schedule for assessing assertive behavior Behav Ther4 398e406
Slater J 1990 Effecting personal effectiveness assertiveness training for nurses J Adv Nurs 15 337e356Sudha R 2005 How to be an assertive nurse Nurs J India 96 (8) 182e183Timmins F McCabe C 2005a How assertive are nurses in the workplace A
preliminary pilot study J Nurs Manag 13 (1) 61e67Timmins F McCabe C 2005b Nurses and midwives assertive behaviour in the
workplace J Adv Nurs 51 (1) 38e45Twenge JM 2001 Changes in womens assertiveness in response to status and
roles a cross-temporal meta-analysis1931e1993 J Person Soc Psychol 81 (1)133e145
J Warland et al Nurse Education in Practice 14 (2014) 752e756 756
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 25
midwiferystudents 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 pro-fessional and autonomous These factors may act to reduce a mid-
wifes 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 speci1047297c 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 neces-
sarily innate and therefore may be learned (Arslan et al 2013
Kilpatrick Forchuk 1992 Lee Crockett 1994 Lin et al 2004)
This paper exploresone 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 identi1047297ed
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 specif-
ically created for use with Irish undergraduate nursing students
We adapted it for use with undergraduate midwifery students by
changing the word ldquopatientrdquo to ldquowomanrdquo The questionnaire
included 28 4 point Likert questions with the options lsquoalwaysrsquo
lsquooftenrsquo lsquorarelyrsquo and lsquoneverrsquo The questions were designed to deter-
mine students current level of assertiveness both in the workplace
and in social settings and had been validated both by the de-
velopers (Begleyamp Glacken 2004) and through a similar study to
ours (Deltsidou 2009) In addition to the assertiveness question-
naire students were also asked their age range and enrolment
status (ie domestic or international)
Approach
The study was designed to measure midwifery students asser-
tiveness immediately prior to the start of the one-day assertivenesstraining 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 1047297rst
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
individuals assertive beliefs and behaviours which can help theindividual change how they view themselves and establish self-
con1047297dence and reduce social anxiety (Lin et al 2008) The
workshop was run by the Principal Consultant of a local Counsel-
ling and Consultancy Service She holds quali1047297cations 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
De1047297nition of assertiveness
Overcoming dif 1047297culties in becoming assertive
Steps in giving assertive criticism
The role of emotional intelligence stress fear control power
respect self-con1047297dence 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 in1047298uence of positional power on ones ability to assert
oneself
what can in1047298uence peoples views of assertive communication
discussion of a coroners report (Lock 2012) in which the mid-
wives 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 eval-
uation survey There was greater than 98 broad agreement
(Strongly agreeAgree) 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 ldquodirect entryrdquo students ldquoregistered nursesrdquo under-
taking our undergraduate midwifery program receive ldquocreditrdquo 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 frac14 41 ()
Age group
19e24 years 23 (56)
25e30 years 6 (15)
31e36 years 3 (7)
37e42 years 5 (12)
gt43 years 2 (5)
Missing 2 (5)
Enrolment status
International student 4 (10)
Domestic student 34(83)Missing 3 (7)
All were female
J Warland et al Nurse Education in Practice 14 (2014) 752e756 753
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 35
Ethical considerations
Ethics approval was gained from the Universitys 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 theirparticipation or non-participation The assertiveness training
workshop was not linked in any way with unit assessment
Data analysis
The assertiveness lsquoscorersquo 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
ldquoalwaysrdquo 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 assertivenessscores 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 688
(range 53e92) (Table 3) The lowest mean score was to question 15
(I am careful to avoid hurting other peoples feelings) The highest
mean score for all questions was to question 3 (I 1047297nd it dif 1047297cult 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 dif 1047297cult
Post workshop assertiveness scores
Following the workshop the mean assertiveness score was 755
(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 ldquoneverrdquo to this reverse scored question
Overall assertiveness scores
Overall the mean assertiveness scores prior to the workshop
was 688 and this improved to 755 ( p frac14 0002) following theworkshop There was an improved score noted to 26 of the 28 in-
dividual 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 statisticallysigni1047297cant changes to individual questions there was a general
tendency for the students to report increased level of assertiveness
Table 2
Workshop participation evaluation data
Question 5 (High) 4 3 2 1 (low) Total
Subject matter 34 7 41
Interest level 22 18 1 41
Objectives 28 13 41Presentation 31 8 2 41
Learning value 23 17 1 41
Participant involvement 29 10 2 41
Table 3
Assertiveness scores
Question Time Average
score
Exact sig
(2 tailed)
1 At work I tend to keep my
feelings to myself
Pre 21 0225
Post 232 I feel uncomfortable asking
a colleague to do a favour
for me
Pre 24 0011
Post 28
3 I 1047297nd it dif 1047297cult to compliment
and praise friends and
acquaintances
Pre 35 0393
Post 36
4 If a senior colleague made an
unreasonable request I
would refuse
Pre 26 0067
Post 29
5 I enjoy starting conversations
with acquaintances and
strangers
Pre 25 0009
Post 295
6 I 1047297nd criticism from friends and
acquaintances hard to take
Pre 24 0276
Post 26
7 I want to know what my rights
are in the work place
Pre 33 0053
Post 36
8 If a friend makes an unreasonable
request I would 1047297nd it dif 1047297cult
to refuse
Pre 25 0039
Post 29
9 I would feel uncomfortable paying
a compliment to a junior colleague
Pre 35 0248
Post 37
10 If I was busy I would ignore the
demands of a senior colleague
Pre 16 0730
Post 165
11 When I know a friends opinion
is wrong I would disagree with
himher
Pre 275 0193
Post 295
12 At work I feel unsure what to say
when I am praised
Pre 25 0234
Post 27
13 I tend to be over-apologetic to
friends and acquaintances
Pre 21 0385
Post 23
14 I try to avoid con1047298ict at work Pre 16 0262
Post 18
15 I am very careful to avoid
hurting other peoples feelings
Pre 15 0256
Post 16
16 In a group I make the decisions Pre 27 0506Post 25
17 I would ask for constructive
criticism about my work
Pre 27 0019
Post 30
18 When I am with friends I am
frank and honest about my
feelings
Pre 31 0282
Post 33
19 If a colleague upsets a woman
(client) I would challenge
himher about it
Pre 25 0978
Post 25
20 If I disagreed with a decision made
by a senior colleague I would tell
himher
Pre 22 0328
Post 24
21 At work I avoid asking questions for
fear of sounding stupid
Pre 26 0008
Post 30
22 I feel uncomfortable asking friends to
do favours for me
Pre 265 0145
Post 29
23 When someone pays me a complimentI feel unsure of what to say Pre 25 0346Post 27
24 If I was impressed by the actions of a
senior colleague I would tell himher
Pre 28 0001
Post 34
25 I tend to be over-apologetic to
colleagues
Pre 21 0487
Post 22
26 I tend to be over-concerned about my
womans (client) welfare
Pre 195 0029
Post 23
27 I would feel uncomfortable expressing
annoyance at a senior colleague
Pre 18 0280
Post 20
28 I am a follower rather than a leader Pre 245 0270
Post 26
Bold text is reversed scored
J Warland et al Nurse Education in Practice 14 (2014) 752e756 754
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 45
pre and post the workshop however this change was only statis-
tically signi1047297cant to questions 2 5 8 17 21 24 and 26 (Table 3)
Of importance is the signi1047297cant improvement ( p frac14 008) to
question 21 ldquoAt work I avoid asking questions for fear of sounding
stupidrdquo as well as question 24 ( p frac14 001) ldquoIf I was impressed by the
actions of a senior colleague I would tell himherrdquo
Age
We divided the cohort into two age groups one under (n frac14 23)
and the other over (n frac14 17) 25 years of age (1 student did not give
her age and so was excluded from this analysis) There was a sta-
tistically signi1047297cant ( p frac14 005) improvement in mean assertiveness
score (from 6815 to 7549) 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 735) this was not
statistically signi1047297cant (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 andafter the workshop
Discussion
There was an overall improvement in self-perceived assertive-
ness scores following the assertiveness training workshop This
provides encouraging evidence that educational institutions that
provide speci1047297c 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 signi1047297cant improvement in
the younger students scores and whilst there was also an
improvement in the overall assertiveness score in the older groupthis was not statistically signi1047297cant As the over 25s 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 oppor-
tunity 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 frac14 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
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 1047297nd new con1047297dence in the work-
place as demonstrated by their signi1047297cantly improved responses toquestions 21 and 24 Many students also re1047298ected their positive
evaluation of the workshop on their personal life by making com-
ments such as
ldquo I identi 1047297ed that I need to be more con 1047297dent and actually know
when to step up and express my concerns when necessary without
undermining my peers authority It was useful for my personal
growthrdquo
ldquo 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 per-
sonal liferdquo
Identi1047297ed barriers that may prevent nurses from being assertive
include lack of knowledge about personalprofessional rightsconcern about what others will think about their behaviour and
anxiety due to a lack of con1047297dence and poor self-esteem (Poroch
and McIntosh 1995) Our study demonstrated an improvement in
understanding rights in a groupwho already seemedto understand
these rights (pre score 33 to post score 36 maximum score 4) We
also found a signi1047297cant improvement in students being prepared to
ask questions even if this was at the expense of ldquosounding stupidrdquo
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 inassertiveness 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 speci1047297c 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-workshopsurvey
could perhaps be assumed to be less assertive than those who
chose to remain in the study and if this was the case their non-
participation 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 (6918) than the remaining respondents
indicating that if these students had participated the post-
workshop 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 con1047297-
dence Providing assertiveness training is therefore an important
part of any undergraduate midwifery programme However dedi-cated assertiveness training is not always part of higher education
and can be costly
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 688 39 53 92 0002
Post 755 29 62 99
Age less than 25 Pre 6815 2 3 53 92 0005
Post 7549 17 62 99Age older than 25 Pre 688 14 56 835 0171
Post 735 12 62 86
J Warland et al Nurse Education in Practice 14 (2014) 752e756 755
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 55
Although the bene1047297ts of teaching this topic have not yet been
empirically tested our pre and post intervention study demon-
strates that there are signi1047297cant and immediate bene1047297ts for student
midwives especially in gaining con1047297dence in asking questions and
not being afraid to compliment their superiors on a job well done
Whilst our students reported feeling more assertive this maynot 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 KN Baser M 2013 Levels of assertiveness and peer pressure of
nursing students Int J caring Sci 6 (1) 78e
86Begley CM Glacken M 2004 Irish nursing students changing levels of asser-
tiveness during their pre-registration programme Nurse Educ Today 24 (7)501e510
Deltsidou A 2009 Undergraduate nursing students level of assertiveness inGreece a questionnaire survey Nurse Educ Pract 9 (5) 322e330
Galassi JP DeLo JS Galassi MD Bastein S 1974 The college self-expressionscale a measure of assertiveness Behav Ther 5 (2) 165e171
Gambrill ED Richey CA 1975 An assertion inventory for use in assessments andresearch 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 andassertiveness in males and females J Youth Adolesc 10 (1) 33e44
Hijazi A Tavakoli S Slavin-Spenny O Lumley M 2011 Targeting interventionsmoderators of the effects of expressive writing and assertiveness training onthe adjustment of international University students Int J Adv Couns 33 (2)101e112
Howard D 2001 Student nurses experiences of project 200 0 Nurs Stand 15 (48)
33e
38Kilkus SP 1993 Assertiveness among professional nurses J Adv Nurs 18 (8)
1324e1330Kilpatrick H Forchuk C 1992 Assertiveness training does it make a difference
J Nurs Staff Dev 8 (2) 60e65Laschinger HKS Leiter M Day A Gilin D 2009 Workplace empowerment
incivility and burnout impact on staff nurse recruitment and retention out-comes J Nurs Manag 17 (3) 302e311
Lawton S Stewart F 2005 Assertiveness making yourself heard in districtnursing Br J Community Nurs 10 (6) 281e283
Lee S Crockett MS 1994 Effect of assertiveness training on levels of stress andassertiveness experienced by nurses in Taiwan Republic of China Issues MentHealth Nurs 15 (4) 419e432
Lin Y-R Shiah I-S Chang Y-C Lai T-J Wang K-Y Chou K-R 2004 Evaluationof assertiveness training program on nursing and medical students assertive-ness self esteem and interpersonal communication satisfaction Nurse EducToday 24 (8) 656e665
Lin Y-R Wu M-H Yang C-I Chen T-H Hsu C-C Chang Y-C Tzeng W-CChou Y-H Chou K-R 2008 Evaluation of assertiveness training for psychi-atric patients J Clin Nurs 17 (21) 2875
e2883
Lock J 2012 Inquest into the Death of Preston Paudel Coroners Court Toowoombaand Brisbane Retrieved 26th March 2014 httpwwwcourtsqldgovau__dataassetspdf_1047297le0005165470cif-paudel-p-20121025pdf
Lounsbury JW Loveland JM Sundstrom ED Gibson LW Drost AWHamrick FL 2003 An investigation of personality traits in relation to careersatisfaction J Career Assess 11 (3) 287e307
Mc Cabe C Timmins F 2003 Teaching assertiveness to undergraduate nursingstudents Nurse Educ Pract 3 (1) 30e42
McCartan PJ Hargie ODW 2004 Assertiveness and caring are they compatible J Clin Nurs 13 (6) 707e713
NMBA 2006 National Competency Standards for the Midwife Nursing andMidwifery Board of Australia Retrieved 26th March 2014 httpwwwnursingmidwiferyboardgovau
Poroch D McIntosh W 1995 Barriers to assertive skills in nurses Aust N Z JMent Health Nurs 4 (3) 113e123
Rathus SA 1973 A 30-item schedule for assessing assertive behavior Behav Ther4 398e406
Slater J 1990 Effecting personal effectiveness assertiveness training for nurses J Adv Nurs 15 337e356Sudha R 2005 How to be an assertive nurse Nurs J India 96 (8) 182e183Timmins F McCabe C 2005a How assertive are nurses in the workplace A
preliminary pilot study J Nurs Manag 13 (1) 61e67Timmins F McCabe C 2005b Nurses and midwives assertive behaviour in the
workplace J Adv Nurs 51 (1) 38e45Twenge JM 2001 Changes in womens assertiveness in response to status and
roles a cross-temporal meta-analysis1931e1993 J Person Soc Psychol 81 (1)133e145
J Warland et al Nurse Education in Practice 14 (2014) 752e756 756
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 35
Ethical considerations
Ethics approval was gained from the Universitys 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 theirparticipation or non-participation The assertiveness training
workshop was not linked in any way with unit assessment
Data analysis
The assertiveness lsquoscorersquo 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
ldquoalwaysrdquo 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 assertivenessscores 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 688
(range 53e92) (Table 3) The lowest mean score was to question 15
(I am careful to avoid hurting other peoples feelings) The highest
mean score for all questions was to question 3 (I 1047297nd it dif 1047297cult 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 dif 1047297cult
Post workshop assertiveness scores
Following the workshop the mean assertiveness score was 755
(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 ldquoneverrdquo to this reverse scored question
Overall assertiveness scores
Overall the mean assertiveness scores prior to the workshop
was 688 and this improved to 755 ( p frac14 0002) following theworkshop There was an improved score noted to 26 of the 28 in-
dividual 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 statisticallysigni1047297cant changes to individual questions there was a general
tendency for the students to report increased level of assertiveness
Table 2
Workshop participation evaluation data
Question 5 (High) 4 3 2 1 (low) Total
Subject matter 34 7 41
Interest level 22 18 1 41
Objectives 28 13 41Presentation 31 8 2 41
Learning value 23 17 1 41
Participant involvement 29 10 2 41
Table 3
Assertiveness scores
Question Time Average
score
Exact sig
(2 tailed)
1 At work I tend to keep my
feelings to myself
Pre 21 0225
Post 232 I feel uncomfortable asking
a colleague to do a favour
for me
Pre 24 0011
Post 28
3 I 1047297nd it dif 1047297cult to compliment
and praise friends and
acquaintances
Pre 35 0393
Post 36
4 If a senior colleague made an
unreasonable request I
would refuse
Pre 26 0067
Post 29
5 I enjoy starting conversations
with acquaintances and
strangers
Pre 25 0009
Post 295
6 I 1047297nd criticism from friends and
acquaintances hard to take
Pre 24 0276
Post 26
7 I want to know what my rights
are in the work place
Pre 33 0053
Post 36
8 If a friend makes an unreasonable
request I would 1047297nd it dif 1047297cult
to refuse
Pre 25 0039
Post 29
9 I would feel uncomfortable paying
a compliment to a junior colleague
Pre 35 0248
Post 37
10 If I was busy I would ignore the
demands of a senior colleague
Pre 16 0730
Post 165
11 When I know a friends opinion
is wrong I would disagree with
himher
Pre 275 0193
Post 295
12 At work I feel unsure what to say
when I am praised
Pre 25 0234
Post 27
13 I tend to be over-apologetic to
friends and acquaintances
Pre 21 0385
Post 23
14 I try to avoid con1047298ict at work Pre 16 0262
Post 18
15 I am very careful to avoid
hurting other peoples feelings
Pre 15 0256
Post 16
16 In a group I make the decisions Pre 27 0506Post 25
17 I would ask for constructive
criticism about my work
Pre 27 0019
Post 30
18 When I am with friends I am
frank and honest about my
feelings
Pre 31 0282
Post 33
19 If a colleague upsets a woman
(client) I would challenge
himher about it
Pre 25 0978
Post 25
20 If I disagreed with a decision made
by a senior colleague I would tell
himher
Pre 22 0328
Post 24
21 At work I avoid asking questions for
fear of sounding stupid
Pre 26 0008
Post 30
22 I feel uncomfortable asking friends to
do favours for me
Pre 265 0145
Post 29
23 When someone pays me a complimentI feel unsure of what to say Pre 25 0346Post 27
24 If I was impressed by the actions of a
senior colleague I would tell himher
Pre 28 0001
Post 34
25 I tend to be over-apologetic to
colleagues
Pre 21 0487
Post 22
26 I tend to be over-concerned about my
womans (client) welfare
Pre 195 0029
Post 23
27 I would feel uncomfortable expressing
annoyance at a senior colleague
Pre 18 0280
Post 20
28 I am a follower rather than a leader Pre 245 0270
Post 26
Bold text is reversed scored
J Warland et al Nurse Education in Practice 14 (2014) 752e756 754
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 45
pre and post the workshop however this change was only statis-
tically signi1047297cant to questions 2 5 8 17 21 24 and 26 (Table 3)
Of importance is the signi1047297cant improvement ( p frac14 008) to
question 21 ldquoAt work I avoid asking questions for fear of sounding
stupidrdquo as well as question 24 ( p frac14 001) ldquoIf I was impressed by the
actions of a senior colleague I would tell himherrdquo
Age
We divided the cohort into two age groups one under (n frac14 23)
and the other over (n frac14 17) 25 years of age (1 student did not give
her age and so was excluded from this analysis) There was a sta-
tistically signi1047297cant ( p frac14 005) improvement in mean assertiveness
score (from 6815 to 7549) 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 735) this was not
statistically signi1047297cant (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 andafter the workshop
Discussion
There was an overall improvement in self-perceived assertive-
ness scores following the assertiveness training workshop This
provides encouraging evidence that educational institutions that
provide speci1047297c 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 signi1047297cant improvement in
the younger students scores and whilst there was also an
improvement in the overall assertiveness score in the older groupthis was not statistically signi1047297cant As the over 25s 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 oppor-
tunity 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 frac14 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
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 1047297nd new con1047297dence in the work-
place as demonstrated by their signi1047297cantly improved responses toquestions 21 and 24 Many students also re1047298ected their positive
evaluation of the workshop on their personal life by making com-
ments such as
ldquo I identi 1047297ed that I need to be more con 1047297dent and actually know
when to step up and express my concerns when necessary without
undermining my peers authority It was useful for my personal
growthrdquo
ldquo 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 per-
sonal liferdquo
Identi1047297ed barriers that may prevent nurses from being assertive
include lack of knowledge about personalprofessional rightsconcern about what others will think about their behaviour and
anxiety due to a lack of con1047297dence and poor self-esteem (Poroch
and McIntosh 1995) Our study demonstrated an improvement in
understanding rights in a groupwho already seemedto understand
these rights (pre score 33 to post score 36 maximum score 4) We
also found a signi1047297cant improvement in students being prepared to
ask questions even if this was at the expense of ldquosounding stupidrdquo
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 inassertiveness 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 speci1047297c 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-workshopsurvey
could perhaps be assumed to be less assertive than those who
chose to remain in the study and if this was the case their non-
participation 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 (6918) than the remaining respondents
indicating that if these students had participated the post-
workshop 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 con1047297-
dence Providing assertiveness training is therefore an important
part of any undergraduate midwifery programme However dedi-cated assertiveness training is not always part of higher education
and can be costly
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 688 39 53 92 0002
Post 755 29 62 99
Age less than 25 Pre 6815 2 3 53 92 0005
Post 7549 17 62 99Age older than 25 Pre 688 14 56 835 0171
Post 735 12 62 86
J Warland et al Nurse Education in Practice 14 (2014) 752e756 755
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 55
Although the bene1047297ts of teaching this topic have not yet been
empirically tested our pre and post intervention study demon-
strates that there are signi1047297cant and immediate bene1047297ts for student
midwives especially in gaining con1047297dence in asking questions and
not being afraid to compliment their superiors on a job well done
Whilst our students reported feeling more assertive this maynot 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 KN Baser M 2013 Levels of assertiveness and peer pressure of
nursing students Int J caring Sci 6 (1) 78e
86Begley CM Glacken M 2004 Irish nursing students changing levels of asser-
tiveness during their pre-registration programme Nurse Educ Today 24 (7)501e510
Deltsidou A 2009 Undergraduate nursing students level of assertiveness inGreece a questionnaire survey Nurse Educ Pract 9 (5) 322e330
Galassi JP DeLo JS Galassi MD Bastein S 1974 The college self-expressionscale a measure of assertiveness Behav Ther 5 (2) 165e171
Gambrill ED Richey CA 1975 An assertion inventory for use in assessments andresearch 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 andassertiveness in males and females J Youth Adolesc 10 (1) 33e44
Hijazi A Tavakoli S Slavin-Spenny O Lumley M 2011 Targeting interventionsmoderators of the effects of expressive writing and assertiveness training onthe adjustment of international University students Int J Adv Couns 33 (2)101e112
Howard D 2001 Student nurses experiences of project 200 0 Nurs Stand 15 (48)
33e
38Kilkus SP 1993 Assertiveness among professional nurses J Adv Nurs 18 (8)
1324e1330Kilpatrick H Forchuk C 1992 Assertiveness training does it make a difference
J Nurs Staff Dev 8 (2) 60e65Laschinger HKS Leiter M Day A Gilin D 2009 Workplace empowerment
incivility and burnout impact on staff nurse recruitment and retention out-comes J Nurs Manag 17 (3) 302e311
Lawton S Stewart F 2005 Assertiveness making yourself heard in districtnursing Br J Community Nurs 10 (6) 281e283
Lee S Crockett MS 1994 Effect of assertiveness training on levels of stress andassertiveness experienced by nurses in Taiwan Republic of China Issues MentHealth Nurs 15 (4) 419e432
Lin Y-R Shiah I-S Chang Y-C Lai T-J Wang K-Y Chou K-R 2004 Evaluationof assertiveness training program on nursing and medical students assertive-ness self esteem and interpersonal communication satisfaction Nurse EducToday 24 (8) 656e665
Lin Y-R Wu M-H Yang C-I Chen T-H Hsu C-C Chang Y-C Tzeng W-CChou Y-H Chou K-R 2008 Evaluation of assertiveness training for psychi-atric patients J Clin Nurs 17 (21) 2875
e2883
Lock J 2012 Inquest into the Death of Preston Paudel Coroners Court Toowoombaand Brisbane Retrieved 26th March 2014 httpwwwcourtsqldgovau__dataassetspdf_1047297le0005165470cif-paudel-p-20121025pdf
Lounsbury JW Loveland JM Sundstrom ED Gibson LW Drost AWHamrick FL 2003 An investigation of personality traits in relation to careersatisfaction J Career Assess 11 (3) 287e307
Mc Cabe C Timmins F 2003 Teaching assertiveness to undergraduate nursingstudents Nurse Educ Pract 3 (1) 30e42
McCartan PJ Hargie ODW 2004 Assertiveness and caring are they compatible J Clin Nurs 13 (6) 707e713
NMBA 2006 National Competency Standards for the Midwife Nursing andMidwifery Board of Australia Retrieved 26th March 2014 httpwwwnursingmidwiferyboardgovau
Poroch D McIntosh W 1995 Barriers to assertive skills in nurses Aust N Z JMent Health Nurs 4 (3) 113e123
Rathus SA 1973 A 30-item schedule for assessing assertive behavior Behav Ther4 398e406
Slater J 1990 Effecting personal effectiveness assertiveness training for nurses J Adv Nurs 15 337e356Sudha R 2005 How to be an assertive nurse Nurs J India 96 (8) 182e183Timmins F McCabe C 2005a How assertive are nurses in the workplace A
preliminary pilot study J Nurs Manag 13 (1) 61e67Timmins F McCabe C 2005b Nurses and midwives assertive behaviour in the
workplace J Adv Nurs 51 (1) 38e45Twenge JM 2001 Changes in womens assertiveness in response to status and
roles a cross-temporal meta-analysis1931e1993 J Person Soc Psychol 81 (1)133e145
J Warland et al Nurse Education in Practice 14 (2014) 752e756 756
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 45
pre and post the workshop however this change was only statis-
tically signi1047297cant to questions 2 5 8 17 21 24 and 26 (Table 3)
Of importance is the signi1047297cant improvement ( p frac14 008) to
question 21 ldquoAt work I avoid asking questions for fear of sounding
stupidrdquo as well as question 24 ( p frac14 001) ldquoIf I was impressed by the
actions of a senior colleague I would tell himherrdquo
Age
We divided the cohort into two age groups one under (n frac14 23)
and the other over (n frac14 17) 25 years of age (1 student did not give
her age and so was excluded from this analysis) There was a sta-
tistically signi1047297cant ( p frac14 005) improvement in mean assertiveness
score (from 6815 to 7549) 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 735) this was not
statistically signi1047297cant (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 andafter the workshop
Discussion
There was an overall improvement in self-perceived assertive-
ness scores following the assertiveness training workshop This
provides encouraging evidence that educational institutions that
provide speci1047297c 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 signi1047297cant improvement in
the younger students scores and whilst there was also an
improvement in the overall assertiveness score in the older groupthis was not statistically signi1047297cant As the over 25s 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 oppor-
tunity 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 frac14 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
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 1047297nd new con1047297dence in the work-
place as demonstrated by their signi1047297cantly improved responses toquestions 21 and 24 Many students also re1047298ected their positive
evaluation of the workshop on their personal life by making com-
ments such as
ldquo I identi 1047297ed that I need to be more con 1047297dent and actually know
when to step up and express my concerns when necessary without
undermining my peers authority It was useful for my personal
growthrdquo
ldquo 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 per-
sonal liferdquo
Identi1047297ed barriers that may prevent nurses from being assertive
include lack of knowledge about personalprofessional rightsconcern about what others will think about their behaviour and
anxiety due to a lack of con1047297dence and poor self-esteem (Poroch
and McIntosh 1995) Our study demonstrated an improvement in
understanding rights in a groupwho already seemedto understand
these rights (pre score 33 to post score 36 maximum score 4) We
also found a signi1047297cant improvement in students being prepared to
ask questions even if this was at the expense of ldquosounding stupidrdquo
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 inassertiveness 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 speci1047297c 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-workshopsurvey
could perhaps be assumed to be less assertive than those who
chose to remain in the study and if this was the case their non-
participation 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 (6918) than the remaining respondents
indicating that if these students had participated the post-
workshop 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 con1047297-
dence Providing assertiveness training is therefore an important
part of any undergraduate midwifery programme However dedi-cated assertiveness training is not always part of higher education
and can be costly
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 688 39 53 92 0002
Post 755 29 62 99
Age less than 25 Pre 6815 2 3 53 92 0005
Post 7549 17 62 99Age older than 25 Pre 688 14 56 835 0171
Post 735 12 62 86
J Warland et al Nurse Education in Practice 14 (2014) 752e756 755
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 55
Although the bene1047297ts of teaching this topic have not yet been
empirically tested our pre and post intervention study demon-
strates that there are signi1047297cant and immediate bene1047297ts for student
midwives especially in gaining con1047297dence in asking questions and
not being afraid to compliment their superiors on a job well done
Whilst our students reported feeling more assertive this maynot 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 KN Baser M 2013 Levels of assertiveness and peer pressure of
nursing students Int J caring Sci 6 (1) 78e
86Begley CM Glacken M 2004 Irish nursing students changing levels of asser-
tiveness during their pre-registration programme Nurse Educ Today 24 (7)501e510
Deltsidou A 2009 Undergraduate nursing students level of assertiveness inGreece a questionnaire survey Nurse Educ Pract 9 (5) 322e330
Galassi JP DeLo JS Galassi MD Bastein S 1974 The college self-expressionscale a measure of assertiveness Behav Ther 5 (2) 165e171
Gambrill ED Richey CA 1975 An assertion inventory for use in assessments andresearch 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 andassertiveness in males and females J Youth Adolesc 10 (1) 33e44
Hijazi A Tavakoli S Slavin-Spenny O Lumley M 2011 Targeting interventionsmoderators of the effects of expressive writing and assertiveness training onthe adjustment of international University students Int J Adv Couns 33 (2)101e112
Howard D 2001 Student nurses experiences of project 200 0 Nurs Stand 15 (48)
33e
38Kilkus SP 1993 Assertiveness among professional nurses J Adv Nurs 18 (8)
1324e1330Kilpatrick H Forchuk C 1992 Assertiveness training does it make a difference
J Nurs Staff Dev 8 (2) 60e65Laschinger HKS Leiter M Day A Gilin D 2009 Workplace empowerment
incivility and burnout impact on staff nurse recruitment and retention out-comes J Nurs Manag 17 (3) 302e311
Lawton S Stewart F 2005 Assertiveness making yourself heard in districtnursing Br J Community Nurs 10 (6) 281e283
Lee S Crockett MS 1994 Effect of assertiveness training on levels of stress andassertiveness experienced by nurses in Taiwan Republic of China Issues MentHealth Nurs 15 (4) 419e432
Lin Y-R Shiah I-S Chang Y-C Lai T-J Wang K-Y Chou K-R 2004 Evaluationof assertiveness training program on nursing and medical students assertive-ness self esteem and interpersonal communication satisfaction Nurse EducToday 24 (8) 656e665
Lin Y-R Wu M-H Yang C-I Chen T-H Hsu C-C Chang Y-C Tzeng W-CChou Y-H Chou K-R 2008 Evaluation of assertiveness training for psychi-atric patients J Clin Nurs 17 (21) 2875
e2883
Lock J 2012 Inquest into the Death of Preston Paudel Coroners Court Toowoombaand Brisbane Retrieved 26th March 2014 httpwwwcourtsqldgovau__dataassetspdf_1047297le0005165470cif-paudel-p-20121025pdf
Lounsbury JW Loveland JM Sundstrom ED Gibson LW Drost AWHamrick FL 2003 An investigation of personality traits in relation to careersatisfaction J Career Assess 11 (3) 287e307
Mc Cabe C Timmins F 2003 Teaching assertiveness to undergraduate nursingstudents Nurse Educ Pract 3 (1) 30e42
McCartan PJ Hargie ODW 2004 Assertiveness and caring are they compatible J Clin Nurs 13 (6) 707e713
NMBA 2006 National Competency Standards for the Midwife Nursing andMidwifery Board of Australia Retrieved 26th March 2014 httpwwwnursingmidwiferyboardgovau
Poroch D McIntosh W 1995 Barriers to assertive skills in nurses Aust N Z JMent Health Nurs 4 (3) 113e123
Rathus SA 1973 A 30-item schedule for assessing assertive behavior Behav Ther4 398e406
Slater J 1990 Effecting personal effectiveness assertiveness training for nurses J Adv Nurs 15 337e356Sudha R 2005 How to be an assertive nurse Nurs J India 96 (8) 182e183Timmins F McCabe C 2005a How assertive are nurses in the workplace A
preliminary pilot study J Nurs Manag 13 (1) 61e67Timmins F McCabe C 2005b Nurses and midwives assertive behaviour in the
workplace J Adv Nurs 51 (1) 38e45Twenge JM 2001 Changes in womens assertiveness in response to status and
roles a cross-temporal meta-analysis1931e1993 J Person Soc Psychol 81 (1)133e145
J Warland et al Nurse Education in Practice 14 (2014) 752e756 756
7212019 Assertiveness Training in Midwives
httpslidepdfcomreaderfullassertiveness-training-in-midwives 55
Although the bene1047297ts of teaching this topic have not yet been
empirically tested our pre and post intervention study demon-
strates that there are signi1047297cant and immediate bene1047297ts for student
midwives especially in gaining con1047297dence in asking questions and
not being afraid to compliment their superiors on a job well done
Whilst our students reported feeling more assertive this maynot 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 KN Baser M 2013 Levels of assertiveness and peer pressure of
nursing students Int J caring Sci 6 (1) 78e
86Begley CM Glacken M 2004 Irish nursing students changing levels of asser-
tiveness during their pre-registration programme Nurse Educ Today 24 (7)501e510
Deltsidou A 2009 Undergraduate nursing students level of assertiveness inGreece a questionnaire survey Nurse Educ Pract 9 (5) 322e330
Galassi JP DeLo JS Galassi MD Bastein S 1974 The college self-expressionscale a measure of assertiveness Behav Ther 5 (2) 165e171
Gambrill ED Richey CA 1975 An assertion inventory for use in assessments andresearch 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 andassertiveness in males and females J Youth Adolesc 10 (1) 33e44
Hijazi A Tavakoli S Slavin-Spenny O Lumley M 2011 Targeting interventionsmoderators of the effects of expressive writing and assertiveness training onthe adjustment of international University students Int J Adv Couns 33 (2)101e112
Howard D 2001 Student nurses experiences of project 200 0 Nurs Stand 15 (48)
33e
38Kilkus SP 1993 Assertiveness among professional nurses J Adv Nurs 18 (8)
1324e1330Kilpatrick H Forchuk C 1992 Assertiveness training does it make a difference
J Nurs Staff Dev 8 (2) 60e65Laschinger HKS Leiter M Day A Gilin D 2009 Workplace empowerment
incivility and burnout impact on staff nurse recruitment and retention out-comes J Nurs Manag 17 (3) 302e311
Lawton S Stewart F 2005 Assertiveness making yourself heard in districtnursing Br J Community Nurs 10 (6) 281e283
Lee S Crockett MS 1994 Effect of assertiveness training on levels of stress andassertiveness experienced by nurses in Taiwan Republic of China Issues MentHealth Nurs 15 (4) 419e432
Lin Y-R Shiah I-S Chang Y-C Lai T-J Wang K-Y Chou K-R 2004 Evaluationof assertiveness training program on nursing and medical students assertive-ness self esteem and interpersonal communication satisfaction Nurse EducToday 24 (8) 656e665
Lin Y-R Wu M-H Yang C-I Chen T-H Hsu C-C Chang Y-C Tzeng W-CChou Y-H Chou K-R 2008 Evaluation of assertiveness training for psychi-atric patients J Clin Nurs 17 (21) 2875
e2883
Lock J 2012 Inquest into the Death of Preston Paudel Coroners Court Toowoombaand Brisbane Retrieved 26th March 2014 httpwwwcourtsqldgovau__dataassetspdf_1047297le0005165470cif-paudel-p-20121025pdf
Lounsbury JW Loveland JM Sundstrom ED Gibson LW Drost AWHamrick FL 2003 An investigation of personality traits in relation to careersatisfaction J Career Assess 11 (3) 287e307
Mc Cabe C Timmins F 2003 Teaching assertiveness to undergraduate nursingstudents Nurse Educ Pract 3 (1) 30e42
McCartan PJ Hargie ODW 2004 Assertiveness and caring are they compatible J Clin Nurs 13 (6) 707e713
NMBA 2006 National Competency Standards for the Midwife Nursing andMidwifery Board of Australia Retrieved 26th March 2014 httpwwwnursingmidwiferyboardgovau
Poroch D McIntosh W 1995 Barriers to assertive skills in nurses Aust N Z JMent Health Nurs 4 (3) 113e123
Rathus SA 1973 A 30-item schedule for assessing assertive behavior Behav Ther4 398e406
Slater J 1990 Effecting personal effectiveness assertiveness training for nurses J Adv Nurs 15 337e356Sudha R 2005 How to be an assertive nurse Nurs J India 96 (8) 182e183Timmins F McCabe C 2005a How assertive are nurses in the workplace A
preliminary pilot study J Nurs Manag 13 (1) 61e67Timmins F McCabe C 2005b Nurses and midwives assertive behaviour in the
workplace J Adv Nurs 51 (1) 38e45Twenge JM 2001 Changes in womens assertiveness in response to status and
roles a cross-temporal meta-analysis1931e1993 J Person Soc Psychol 81 (1)133e145
J Warland et al Nurse Education in Practice 14 (2014) 752e756 756