How We Can Enhance Nurses’ Assertiveness: A Literature Review Ayako Okuyama1
Cordula Wagner2,3 and Bart Bijnen4,5
1Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, Osaka, Japan 2EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands 3NIVEL Netherlands Institute for Health Services Research, Utrecht, The Netherlands 4Institute for Education and Training, VU University Medical Centre, Amsterdam, The Netherlands 5Foreest Medical School, Medical Centre Alkmaar, Alkmaar, The Netherlands *Corresponding author: Ayako Okuyama, Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan, Tel : +81-6-6879-2555; E-mail: [email protected]
Received date: June 10, 2014, Accepted date: August 25, 2014, Published date: August 28, 2014
Copyright: © 2014 Okuyama A et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objective : Assertiveness is important for effective team building in nursing. This article aims at evaluating the results of the previous studies on nurses’ assertiveness in each decade in order to discuss the possible ways for enhancing nurses’ assertiveness.
Methods : Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were searched for English-language articles published from 1946 to December 2012. Article which described the assertiveness of nurses and relevant factors related to assertiveness in a clinical setting or evaluated assertiveness training.
Results : Twenty-five studies in 26 articles were identified. In the 1970s and 1980s, research demonstrated that nurses perceived they are submissive helper and were less assertive. These studies indicated that educational achievement was regarded as a key factor in nurses’ assertiveness. The study in 1990s demonstrated that at least one population of nurses was assertive. The studies after 2000 suggested that nurses behave in a passive way, conforming to the stereotype of a ‘nice’ nurse, and were less likely to disagree with others. A sense of responsibility for patients, managers’ leadership, organisational culture, and relationship between colleagues were reported as influencing factors of nurses’ assertiveness.
Conclusion : Recently, the number of nurses who are trained in higher educational institutions has increased. Despite this, nurses still experience some difficulties assessing themselves. Nurses should understand their role at the recent health care environment as a professional. Nurse managers should take a leadership to avoid nurses’ concerns of voicing their opinions in order to improve nurses’ assertiveness.
Keywords: Assertiveness; Interdisciplinary communication; Quality of health care; Systematic review
Introduction Nursing surveillance and monitoring activities are essential for the
patient care [1]. Nurses require the competence of clinical grasp (e.g. what is happening to a patient) and clinical forethought (e.g. prediction for patient condition) for providing patient appropriate care [2]. Nurses are expected to show clinical leadership at the patient bedside to provide direction and support to patients and the health care team for integrating the care they provide to achieve positive patient outcomes [3]. If necessary they assert their opinions to other team members for changing the care plan for their patients [2]. On the other hand, it has been shown that those who are aware of a problem often either speak up and are ignored or do not speak up at all [4,5].
Assertiveness is a style of communication that enables nurses to build effective team relationships. Collaboration with other team members needs both a high level of assertiveness (meeting the own need) and a high level of cooperation (meeting the other’s need) [6].
Assertiveness is described as expressing thoughts and feelings without denying the rights of others [7]. Nurses’ ability to be assertive when they are unsure or concerned about medical procedures, the treatment of patients, or symptoms of patients is key in reducing risk and preventing major medical errors [8]. Assertive people inform others of their needs and feelings, and communicate their message effectively without causing offence to others [9]. When nurses act assertively, they are more likely to provide patients appropriate care, and in doing so, improve the quality of patient care [2,9].
Traditionally, nurses tend to be female and their role involves assisting a doctor. As they play a supporting role, they are often placed lower in the medical hierarchy, and it makes nurses difficult to assert their own opinions for the patient care. Recently nurses’ role in the clinical setting is changing. Since the Institute of Medicine published the report of ‘The Future of Nursing: leading change, advancing health’ in 2011, nurses are expected to act as partners with other health care professionals and to lead in the improvement and redesign of the health care system [10]. In addition, nurses are crucial in preventing medical errors, reducing rates of infection, and even facilitating patients’ transition from hospital to home [10]. It means that nurses
Nursing and Care Okuyama et al., J Nurs Care 2014, 3:5 http://dx.doi.org/10.4172/2167-1168.1000194
Review Article Open Access
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are expected to acquire assertiveness in order to work effectively with other health care professionals.
Lyndon conducted a literature review of nurses’ assertiveness and teamwork, and reported that two studies of assertiveness showed conflicting results [11]: Gerry in 1989 found that nurses rated themselves more assertive outside of work than at work and demonstrated a trend toward conflict avoidance [12], while Kilkus in 1993 found that nurses had mean scores in the moderately assertive [13]. She concluded that findings regarding nurses’ assertiveness were mixed [11]. She evaluated the results of the previous studies on nurses’ assertiveness using only six articles, and did not take into account the changes of nurses’ work environment. Therefore, this review aims at evaluating the results of the previous studies on nurses’ assertiveness each decade in order to discuss the possible ways for enhancing nurses’ assertiveness.
Methods This review was conducted as a part of systematic review for health
care professionals’ voicing behaviour. In the process of the literature review, we found two types of articles pertaining to clinicians’ communication behaviour: the first focussed on speaking-up behaviour related to patient safety (i.e. when clinicians are aware of risky or negligent actions of others within health care teams) and the second investigated the assertiveness of nurses more generally, without focusing on patient safety issues. This article summarises the literature on the latter type of assertiveness in nurses and discusses a strategy to enhance team communication. Our findings on speaking up behaviours in situations related to patient safety are reported elsewhere [14].
Search methods
Relevant articles published in English from 1946 until December 2012 were searched using PubMED, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CIHNAL), Web of Science, and the Cochrane Library (date last searched 24 December 2012). Combinations of terms were used to find articles related to assertiveness (i.e. speak* up, speak* out, assertive*), inter-professional relations (i.e. inter-professional relations, doctor-nurse relationships), health personnel (i.e. health personnel, patient care team, nursing- supervisory, attitude of health personnel, professional role, professional practice), and patient safety (i.e. risk management, safety, medical errors, malpractice, professional misconduct, quality of health care, outcomes and process assessment, program evaluation, quality of health care, outcome and process assessment, program evaluation, quality assurance, consumer satisfaction, doctor’s practice patterns, nurse’s practice patterns, practice management) . Medical Subject Headings were used where available. The search was conducted with the assistance of experts in the use of such databases.
Moreover, a manual search (that involved reading the title of each paper in the journal’s archives) was conducted to find relevant papers on organisational research and nursing management in the Journal of Nursing Management and the Journal of Organizational Behavior. The referenced articles listed in each of the selected publications were also examined.
To obtain a wide variety of research evidence, this review prioritised articles that appeared to be relevant to nurses’ assertiveness rather than particular study types or articles that met particular methodological standards [15]. Both quantitative and qualitative studies were included
in this review. Articles that were selected for use in the review either described the assertiveness of nurses and relevant factors related to assertiveness in a clinical setting. In addition, articles which evaluated the assertive training using the comparative study design were also selected, while articles that described training programmes without any results or expert validation were excluded. Review article of nurses’ assertiveness were also excluded, and here original articles which mentioned in the review were used for the analysis. At first, we searched for assertive behaviour associated with doctors, medical residents, and nurses. However, we did not find any research articles on the assertive behaviour of doctors and medical residents, using our criteria. Therefore, this article deals with only the literature concerning assertive behaviour in nurses.
Two independent reviewers (AO, and a research assistant) reviewed the titles and abstracts of citations generated by the search to assess their eligibility for further review based on the selection criteria. They selected relevant articles for possible inclusion. Cohen’s kappa was calculated to assess the degree of agreement between both reviewers. The reviewers assessed all of the selected articles in relation to the criteria and decided independently which articles to include in this study. In the case of disagreement between the two reviewers, the article was discussed with the other two authors (CW, BB).
Search outcome
The initial search identified 2,941 citations. Most of the excluded 2,649 articles were based solely on expert opinions and commentary, or did not study assertiveness in health care teams. In total, 292 articles meeting the inclusion criteria were selected for detailed review (Figure 1). Following a title and abstract review by the aforementioned two reviewers, Cohen’s kappa was calculated as 0.64.
Twenty articles dealt with the assertiveness of nurses. In addition, five other articles were retrieved from article reference lists, and one article was found using a manual search. In total, 25 studies in 26 articles were identified for this study. Nine articles (35%) were published after the year 2000. Fifteen studies (60%) came from the U.S., and of the remaining ten, eight originated from Japan, Australia, Canada, and Ireland (two from each of these countries).
Quality appraisal
The following criteria were used to assess primary study quality: (1) the aims and objectives of the research are clearly stated, (2) the design is clearly specified and appropriate for the aims and objectives of the research, (3) the researchers provide a clear account of the process by which their findings were reproduced, (4) the researchers include enough data to support their interpretations and conclusions, and (5) the method of analysis is appropriate and adequately executed [15]. In addition, we evaluated the study on the training intervention using the modified Best Medical Education Coding sheet (e.g., study design, participants allocation, outcome level (Kirkpatrick level))[16]. The results of the study appraisal are shown in each table.
Data abstraction
Two reviewers independently abstracted the data from the selected articles (e.g. study aim, design, method, results, and country where the study was conducted).
Synthesis
Nurses’ assertiveness may influence on the trend of the times (e.g. nurses’ work environment), therefore, themes emerged for each decade that research on assertiveness was conducted.