Nurse Education Today 31 (2011) 356–360

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Factors affecting assertiveness among student nurses

Sanaa Abd El Azim Ibrahim
Faculty of Nursing, Port-Said University, Egypt

a r t i c l e i n f o s u m m a r y

Article history: This study aimed to investigate the factors affecting assertiveness among student nurses. The study was
Accepted 19 July 2010 carried out at Faculty of Nursing, Port-Said University, on 207 student nurses from four different grades.
Rathus Assertiveness Schedule, consisted of 30 items, was used to measure the students' assertiveness level
Keywords: and a 12-item scale developed by Spreitzer was used to measure students' psychological empowerment. The
Assertiveness
study results showed that 60.4% of the students were assertive, while about half of the students were
Psychological empowerment
Student nurses
empowered. A positive relation between student assertiveness and psychological empowerment was
detected. Moreover, positive relations regarding family income and students' assertiveness and psychological
empowerment were determined. The study recommended introduction of specific courses aiming at
enhancing the acquisition of assertiveness skills, in addition, nurse educators must motivate their students to
express their opinion and personal rights and also they must pay attention for students' empowerment and
enhance students' autonomy.
© 2010 Elsevier Ltd. All rights reserved.

Introduction Timmins, 2003). Barriers that prevent nurses from being assertive as
mentioned by Burnard (1992), Poroch and McIntosh (1995), and
Nursing takes place within health care organizations and requires Farrell (2001) included lack of knowledge about personal/profession-
effective communication with everyone involved, in order to ensure al rights, concern about what others will think about their behavior,
competent and safe practice (Sully and Nicol, 2005). Assertiveness is a and anxiety due to lack of confidence and poor self-esteem,
communication style, which is considered an important behavior for aggression, fear of other people's hostility, afraid of anger or negative
today's professional nurse and the key to successful relationships with responses, and demand correct and fair treatment. Poor presentation
clients, families, and colleagues (Riley, 2000). Assertiveness refers to and poor self expression are unhealthy for both nurses and patients
the ability to express one's feelings, opinions, beliefs, and needs and clearly require assertive practices. In the same context, O'Mara
directly, openly and honestly, while not violating the personal rights (1995) claimed that nurses' sense of inferiority and lack of
of others (Ellis and Hartley, 2005; Hopkins, 2007). Moreover, assertiveness skills could possibly be picked up by the patient. He
assertiveness is a communication process universally pivotal to questioned whether or not nurses are capable of empowering patients
every avenue of professional nursing practice as nurses advocate for if they themselves are powerless. He contended that if the nurse is not
patients, families, communities and for the profession itself, it enables assertive, there might be an inadequate nurse/patient communica-
the nurses to become more independent, decision-maker and avoid tion. Nurses play a vital communication role in the healthcare system,
the invitation of aggression when the rights of others are violated and advocacy and empowerment are central to this. In this respect,
(Riley, 2000; Hunt-Slamow, 2007). Studies have shown that indivi- O'Mara (1995) suggested that to empower their patients, nurses need
duals who have assertive behaviors generally have higher self-worth to be assertive. Hokansen-Hawks and Hromek (1992) defined the
and are more successful in life (Yılmaz, 2000; Ayaz, 2002; Bal, 2003). concept of empowerment in nursing education as an interpersonal
Little is known about the assertive behavior of student nurses. In this process in which educators provide the tools and an environment
respect Gilmartin (2000) found that some student nurses lacked conducive to increasing autonomous decision making in students. An
confidence, while others lacked basic communication skills. Asser- empowering faculty facilitates discovery and personalizes learning
tiveness is necessary for effective nurse/patient communication, and rather than promoting standardization of content. Today, strategies
it is suggested that its development may also aid the confidence of the that empower or support the equitable distribution of power in
profession as it develops. Assertive behavior may be encouraged student nurses are advocated (Meleis, 2001). The Joint Commission
through educational methods. It is preferable that nurses receive this on Accreditation of Health Organizations (JCAHO, 2002) stated that
educational preparation during undergraduate programs (Cabe and the priority of nursing education should focus on creating a
foundation for bolstering nursing education programs on adapting
characteristics that empower individuals. In order to meet these
E-mail address: sanaaahmed4@[Link]. challenges, teaching strategies and styles of interacting with students

0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/[Link].2010.07.006
 S.A.E.A. Ibrahim / Nurse Education Today 31 (2011) 356–360 357

need to be congruent with the students' context (Oermann, 2004). Subjects

Empowerment is the fruit of trust (Andrews, 1994). Considering the
complex health care system of today, it is time to assess whether The study involved student nurses selected from different
nursing faculties are preparing student nurses to function autono- scholarly levels, from first to fourth year. Determination of sample
mously to meet the challenging roles of the profession (Adams et al., size of student nurses was based on Kish and Leslie (1965), whereas
2002). Empowerment, which generally may be defined in terms of the estimated proportion of degree of assertiveness is 65% (pilot
giving power, giving capacity, to energize, or to enable, has relatively study). The calculated sample size was 207 student nurses who were
recently been given both a firm theoretical framework (Conger and chosen from different scholarly levels using systematic random
Kanungo, 1988; Thomas and Velthouse, 1990), and a rigorous sample.
definition in several studies, Spreitzer (1992, 1995a, 1997) has
focused on psychological empowerment at the workplace, which Tools of data collection
defined in terms of sense of meaning, competence, self determination
and impact. The psychologically empowered was considered to be a The tool for data collection was a questionnaire composed of three
cognitive state characterized by a sense of perceived control, parts. The first part was developed by the researcher to collect data
perceptions of competence, and internalization of the goals and related to personal characteristics of student nurses, such as; age,
objectives. Kenny (2004) purports that the preparation of nurses for scholarly level, residence, family income., etc. The second part was
clinical practice has always been a contentious issue and there is a “Rathus Assertiveness Schedule” (RAS) (1973) which aimed at
need for faculty to focus on better alignment of goals between determining level of assertiveness. This instrument includes 30
education and practice. One such process to facilitate the develop- items, 17 out of all items were reversed to avoid response bias.
ment of autonomy in students through teaching/learning strategies is Scoring as + 3, extremely descriptive; + 2, quite descriptive;
learner empowerment. Although there are indications in the + 1slightly descriptive; − 1 slightly nondescriptive; − 2, quite
literature that empowerment through teaching may liberate and nondescriptive; and − 3, extremely nondescriptive. The scores
enable students to become autonomous, evidence to support these obtained ranged from −90 to + 90. Those who receive below +10
assertions is limited (Wade, 1999). The problem we have today is that as the total score from the tool are considered to be shy or non
the traditional learning environment is not empowering nor does it assertive and those with a score above +10 are considered to be
prepare students to become autonomous and assertive learners assertive.
(Diekelmann, 2002; Diekelmann and Ironside, 2002; Young and The third part is a 12-item scale developed by Spreitzer (1996),
Diekelmann, 2002). Student nurses today are the nucleus of which was used to measure empowerment. It was divided into four
professional nurses of tomorrow. When communication is an integral dimensions namely; meaning, self determination, competence and
part of the nurses' role, from Walczak and Absolon (2001) point of impact and every dimension includes three questions. Response
view, it is crucial to highlight the factors which can affect the student options ranged from (1) “strongly disagree” to (7) “strongly agree”. To
nurses to behave in assertive manner. estimate the cut of point, the median was calculated (58) and divided
by the total score of psychological empowerment (84) giving a result
Aim of the study (0.694); these scores were converted into a percentage score (cut of
point 69%). The subject was considered empowered if the percentage
The study aimed to investigate the factors affecting assertiveness score was 69% or more and not empowered if less than 69%. Alpha
among student nurses throughout the following objectives: Crombach test was used to test the reliabilities of assertiveness
questionnaire and psychological empowerment. Alpha scores for the
1- Determine students' nurses level of assertiveness. assertiveness and psychological empowerment were (0.79, and 0.81)
2- Identify the psychological empowerment among student nurses. respectively, which indicates that the tool is reliable.
3- Find out the relations between students, personal characteristics,
psychological empowerment and student nurses assertiveness.
Methods

Research questions
1- Ethical considerations:
An ethical approval was obtained from the Dean of the Faculty of
1- What is the student nurses level of assertiveness? Nursing and verbal consent was obtained from the student nurses
2- Are student nurses have psychological empowerment? before distributing the questionnaires and after explanation of the
3- Is there a correlation students personal characteristics, psycho- purpose of the study; anonymity was assured and maintained; no
logical empowerment and student nurses' assertiveness? burden or risk was imposed on students; no coercion or pressure
was applied.
Subjects and methods 2- Translation of the questionnaire:
The questionnaires were translated into Arabic version by the
Study design author. To ensure the validity of translation, back translation
technique was used by an expert in English language from Faculty
A descriptive analytical design was used in this study. of Education, English major. Two lecturers from the Faculty of
Nursing reviewed the two versions, and modifications were made
Setting accordingly.
3- Pilot study
The study was carried out at Faculty of Nursing, Port-Said A pilot study was carried out on twenty student nurses to estimate
University, Egypt. The faculty's approach in teaching is problem the number of students involved for data collection, and to
based learning, so the students have a chance for open communica- ascertain the clarity and applicability of the tools. Needed
tion and expressions, through the debriefing sessions, beside modifications were done based on analysis of the pilot results.
immediate evaluation provided to their tutors. This process is not Those students who shared in the pilot study were excluded from
followed in other faculties of nursing in Egypt except in Port-Said the main study sample. The data were collected by using a
faculty since it started, 1991. structured interview questionnaire.
358 S.A.E.A. Ibrahim / Nurse Education Today 31 (2011) 356–360

Table 1 Table 3
Assertiveness among students according to different scholarly level. Correlation between assertiveness, and psychological empowerment, and demographic
characteristics.
Assertiveness Scholarly level Total
Assertiveness Psychological
First Second Third Fourth
empowerment
year year year year
r p r p
N % N % N % N % N %
Psychological empowerment 0.003 0.980
Assertive 40 62.5 10 50.0 34 54.8 41 67.2 125 60.4
Demographic characteristics
Non assertive 24 37.5 10 50.0 28 45.2 20 32.8 82 39.6
Age 0.065 0.514 − 0.032 0.748
Residence (village) − 191⁎ 0.054 − 0.135 0.178
Family income 0.209⁎ 0.035 007 0.946
⁎Correlation is significant at the 0.05 level.
Results

The student nurses included in this study were 207; and the
response rate was 100%. The age of the studied student nurses ranged
from 17 to 22. About two thirds of them were from rural areas, and the and provide the care for patients and their families, and society in the
highest percentage of them recorded by second and third grade areas of health and education in the future, to be individuals with high
students (90% and 71% respectively). 40% of the total students were self-esteem and assertiveness in order to be able to establish
ranked as the first child in their family; most of them (80%), their communication more comfortably in society and to be able to use
family income did not match their needs. Table 1 displays assertive- their professional knowledge and skills more effectively (Diaz and
ness among nurses, as shown in the table slightly more than three McMillin, 1991; Charney, 1994; Kisa and Dziegielewski, 1996). The
fifth of students were assertive (60.4%), ordered as fourth year, first results of the present study revealed that the first and fourth year
year, and third year (67.2%, 62.5%, and 54.8%, respectively), while half students expressed the highest percentage of assertiveness, while the
of the studied second year students were assertiveness. As regards second year recorded the least percentage. In this respect, El-Shimy in
psychological empowerment as expressed by students nurses is Mohamed (1999) carried a study on assertiveness among nursing
shown in Table 2, and the findings revealed that 50% of the students professionals working at Ain Shams University Hospitals, which
were empowered among the first, third and fourth grades while more concluded that the assertiveness of the first year students of the high
than two thirds (70%) of second year students were empowered, As institutes of nursing was significantly higher than that of the interns.
the table shows, the majority of second year students (80%) were Moreover, Begley and Glacken (2004) reported in a study carried out
empowered as regards meaning of their work, while the least percent in Southern Ireland that the assertiveness raised as student nurses
recorded by fourth year (31%) was related to self determination. approached completion of their three-year education program. In the
Table 3 displays correlation between assertiveness, psychological same line, Zerwekh and Claborn (2003) mentioned that, many nurses
empowerment and demographic characteristics; the table shows that do not consistently act or communicate in an assertive way, because
there is positive relation between student assertiveness and psycho- some nurses had a hard time believing in their own rights, feelings, or
logical empowerment, while there is a negative relation between needs. Moreover, Poroch and McIntosh (1995) claimed that nurses
psychological empowerment and student age which means that the lack assertiveness skills, and that this deficiency in assertiveness
older students are less psychologically empowered. Positive relations results in diminished communication efficacy, thus compromising
were found as regards adequate family income yield assertive and patient care. The study findings were contradicted with Yılmaz
empowered students. Statistically significant correlation was detected (2000), who mentioned that the highest assertiveness levels were in
in relation to assertiveness and residence and family income. As the second year university students, and as the year increased,
shown in Table 4; relations between assertiveness as a dependent assertiveness levels decreased. The psychological approach to em-
variable, and personal characteristics and psychological empower- powerment focused on the intrinsic motivation and comprises four
ment as independent variables. It reveals that when psychological different cognitive dimensions: meaning, competence, autonomy and
empowerment increased, assertiveness increased by negligible ratio impact (Thomas and Velthouse, 1990; Spreitzer, 1995b; Dee et al.,
(0.005), also when family income increased, assertiveness increased 2003; Mailloux, 2006). In spite of self learning and problem based
by 0.004. No significant difference appears in the table. learning approaches adopted by the Faculty of Nursing affiliated to
Port-Said University, it encourages students to open communication
and discussion and evaluating faculty members through problem
Discussion solving and debriefing sessions, findings showed that totally, about
half of the students were empowered, the least percentages gone with
It is necessary for university students nurses who will interact with the fourth year regarding self determination, and competency, and
their colleagues and other health care professionals on a daily basis the majority of the second year students were empowered as regards

Table 2
Psychological empowerment as expressed by student nurses.

Psychological Scholarly level Total

empowerment
First year n = 64 Second year n = 20 Third year n = 62 Fourth year n = 61 n = 207
items
Empowered Empowered Empowered Empowered Empowered

No % No % No % No % No %

Meaning 30 47 16 80 36 58 33 54 115 56
Self determination 38 59 8 40 41 66 19 31 106 51
Competency 38 59 12 60 20 32 31 51 101 49
Impact 36 56 14 70 32 52 24 39 106 51
Total 32 50 14 70 32 52 29 48 107 52
 S.A.E.A. Ibrahim / Nurse Education Today 31 (2011) 356–360 359

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