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



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



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


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




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




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




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














Data analysis











Results























Table 2








Table 3



score

Exact sig

(2 tailed)


feelings to myself

Pre 21 0225



for me

Pre 24 0011

Post 28



acquaintances

Pre 35 0393

Post 36



would refuse

Pre 26 0067

Post 29



strangers

Pre 25 0009

Post 295



Pre 24 0276

Post 26



Pre 33 0053

Post 36



to refuse

Pre 25 0039

Post 29



Pre 35 0248

Post 37



Pre 16 0730

Post 165



himher

Pre 275 0193

Post 295


when I am praised

Pre 25 0234

Post 27



Pre 21 0385

Post 23


Post 18



Pre 15 0256

Post 16




Pre 27 0019

Post 30



feelings

Pre 31 0282

Post 33



himher about it

Pre 25 0978

Post 25



himher

Pre 22 0328

Post 24



Pre 26 0008

Post 30


do favours for me

Pre 265 0145

Post 29




Pre 28 0001

Post 34


colleagues

Pre 21 0487

Post 22



Pre 195 0029

Post 23



Pre 18 0280

Post 20


Post 26











Age












Discussion


























warranted








ments such as




growthrdquo



sonal liferdquo











Limitations





















Conclusions






and can be costly

Table 4



Group Time Mean

score

n Minimum

score

Maximum

score

Exact sig

(2-tailed)


Post 755 29 62 99

Age less than 25 Pre 6815 2 3 53 92 0005


Post 735 12 62 86
























Acknowledgements



very busy year


training


References












33e









e2883

























Data analysis











Results























Table 2








Table 3



score

Exact sig

(2 tailed)


feelings to myself

Pre 21 0225



for me

Pre 24 0011

Post 28



acquaintances

Pre 35 0393

Post 36



would refuse

Pre 26 0067

Post 29



strangers

Pre 25 0009

Post 295



Pre 24 0276

Post 26



Pre 33 0053

Post 36



to refuse

Pre 25 0039

Post 29



Pre 35 0248

Post 37



Pre 16 0730

Post 165



himher

Pre 275 0193

Post 295


when I am praised

Pre 25 0234

Post 27



Pre 21 0385

Post 23


Post 18



Pre 15 0256

Post 16




Pre 27 0019

Post 30



feelings

Pre 31 0282

Post 33



himher about it

Pre 25 0978

Post 25



himher

Pre 22 0328

Post 24



Pre 26 0008

Post 30


do favours for me

Pre 265 0145

Post 29




Pre 28 0001

Post 34


colleagues

Pre 21 0487

Post 22



Pre 195 0029

Post 23



Pre 18 0280

Post 20


Post 26











Age












Discussion


























warranted








ments such as




growthrdquo



sonal liferdquo











Limitations





















Conclusions






and can be costly

Table 4



Group Time Mean

score

n Minimum

score

Maximum

score

Exact sig

(2-tailed)


Post 755 29 62 99

Age less than 25 Pre 6815 2 3 53 92 0005


Post 735 12 62 86
























Acknowledgements



very busy year


training


References












33e









e2883





















Age












Discussion


























warranted








ments such as




growthrdquo



sonal liferdquo











Limitations





















Conclusions






and can be costly

Table 4



Group Time Mean

score

n Minimum

score

Maximum

score

Exact sig

(2-tailed)


Post 755 29 62 99

Age less than 25 Pre 6815 2 3 53 92 0005


Post 735 12 62 86
























Acknowledgements



very busy year


training


References












33e









e2883



































Acknowledgements



very busy year


training


References












33e









e2883













assertiveness training in midwives

Documents